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"k t AR ION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 4447, <br /> OM <br /> 1 <br /> `` _ 5155 SiiIverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503)588-7948 <br /> http://ww .co.maaion.o :usfPW/Buildia;1nspe Lion <br /> 2t4-0-036101 Pal <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I. _ .- C 1. 0 c "u.__ a" ' e. _.__ _ __have au ti o•i z <br /> (Property Owner I Print Name) <br /> Lee Bethel-Bethel Ex avating to act as. my agent in performing ti <br /> (Authorized Representative I Print Name) <br /> activities necessary to obtain site evaluations, permits, and other onsite wastewater treatment progra <br /> services provided by the Department of Environmental Quality or County Allem on the proper <br /> described below in accordance with OAR chapter 340, division 0 i I_ <br /> PROPERTY IDENTIFICATION: <br /> S7441 ceito Lei S ' <br /> Property.Situ_s or Street Address <br /> Described in the records of MARION County as: <br /> � L.9 8 Da 2. <br /> Legal Description 51iti-t+ 1 t__Vke . st re, Tax Lot g(s) 6/241•5-... <br /> Subdivision,Lot and Block _ . .r- <br /> PROPERTY OWNER: . <br /> Printed Nam. _ riV. . n="..,Y'l r_ -.-a, ) -�d signature- -d, <br /> _ . _ ,, .. Date: j 3O x21 <br /> Address: 3 / 11 .e_ko L.61 J-. ..-a _ Phone:503 --7i 27 ,'' <br /> City, State, Zip Itt.R.Y_..), eR 1 0 R__.9.1 3 92- F.ax_Af _.._ -. <br /> E-mail Address ier Z �'s d l:z <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel <br /> company Name: Bethel E cavating. <br /> Si=gnature: _ Date: <br /> Address: PO Box 604-6976 Little Rd SE phone: 503 743-2343 <br /> City, State, Zip._..._Tumer, OR 97392 Fax: NA <br /> _____ __�.....� ,.���.�..�- <br /> E-mail Address office@bethelexc.com <br /> -... .. �., _ <br /> DE( License T 36198 . - __..._..,____ .._ CCB :` 4455 l m.� w _.,„ _ <br /> G--:ruRms'.sEp'ric`:s47.At.rrf:TO AM_Y.00)1: .mot 3:'10.3.3S <br />