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�t' <br /> MARION COUNTY PUBLIC WORKS RLCIENE <br /> III I BUILDING INSPECTION DIVISION <br /> III. <br /> mi..„----..---.....-------... ...:.-=......7., 5155 Silverton Rd NE APR 3 0 202E <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 0 <br /> MARION COUNTY <br /> http://ww�v.co.marion.or.us/PWBuildinp,Inspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> , 7/\Ji 7 17i) vnt< have authorized <br /> (Property Owner/Print Name) <br /> Lee Bethel-Bethel Excavating to act as my agent in performing the <br /> (Authorized Representative I Print Name) <br /> activities necessary to obtain site evaluations,permits,and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> 6716 A.ytM vI( .e qv'-Y .4c.4✓1/\ a7, aF•15` <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description • Tax Lot#(s) 5-al 5 5 _ <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: 9AV 1 S D 1)4o 2e <br /> Signature: ��— Date: -Z6f-Z9 <br /> Address: 9 L1 Gi42 r'1y iz<l 5 yo,6 Phone: 74-d s- .5- /6,g l <br /> City,State,Zip 11.,..1_-=_✓t/\ d Fax: <br /> E-mail Address �,tgge r DJ..( rc(a op,(ch r",fill <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel <br /> Company Name: Bethel Excavating <br /> �/ <br /> Signature: � �3aie4( Date: y be,/1t1 <br /> Address: PO Box 504-6976 Little Rd SE Phone: 503-743-2343 <br /> City,State,Zip Turner,OR 97392 Fax: NA <br /> E-mail Address office@bethelexc.com <br /> DEQ License# 36198 CCB# 44551 <br /> GAFORMSIS£PTIC1S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br /> 1 <br />