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nl 1-ki.„,,r.. MARION COUNTY PUBLIC WORKS NI <br /> _ BUILDING INSPECTION DIVISION19 <br /> -%K �� 5155 Silverton Rd NE <br /> iii-----„,„...„, <br /> Salem OR 97305 St? 2 0 2023 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.onus/PW/Buildinglnspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1 5rF ItLJh7EZ rzf have authorized <br /> (Property Owner/Print Name) <br /> Lee Bethel-Bethel Excavating to act as my agent in performing the <br /> (Authorized Representative/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 /> / 7 9,2 i-.z3,5 y z—/v se- ZefF Sav o 4 97;So- <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> • <br /> PROPERTY OWNER: <br /> Printed Name: Z fF GUI-fir 7FZ-ef <br /> Signature: /_;.,/i Date: 9-� -?3 <br /> 1a �-�Address: / 93/63 G.i Se- Phone: 5W 5/0-/7 ' <br /> City, State,Zip T.F-- SOLI/" OA 973S� Fax: <br /> E-mail Address AAr-D vb-2v/W44,- Y/fi C V-1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel <br /> Company Name: Bethel Excavating� � <br /> Signature: Cx=4)o.( Date: <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 /> G:WORMS\SEPTIC\.S-07 AUTH TO APPLY.DOCX Rev 3/10,3/13 <br />