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4k MARION COUNTY PUBLIC WORKS <br /> '��� ""� BUILDING INSPECTION DIVISION <br /> i 11 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> ;= http:/hvww.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Of I ryliai 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 /> 1- <br /> roperty Situs or Street Ad ress <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot a(s) 5301 q <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name:6t i rn ,Qj11DVinsj( <br /> Signature: Date: V�O/_/,L <br /> Address: `i �� �(J(/t4A0 Phone: ifs I -e <br /> City,State,ZipQJ jLQ ) j D O Fax: <br /> ja1ry O O> 0�G! 1 O-n ") <br /> E-mail Address if 1► <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel !j <br /> Company Name: <br /> Bethel Excavating <br /> Signature: '( Date: 21117,1.1 <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 /> GAFORMSISEPTIC4S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />