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_ <br /> �^ MARION COUNTY PUBLIC WORKS <br /> ""' BUILDING INSPECTION DIVISION <br /> _�%l��` �'• 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, E I ZCA,b t1 Y t D 141105 s ,have authorized <br /> (Property Owner/Print Name) <br /> Katie Ryan 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 /> 37 95 Fr crV. . :n ? cur -e <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWN <br /> ER: <br /> Z�,NER: ] / <br /> Printed Name: r J I e)-- l I) . f 4-e�I (l�s <br /> Signature: J fib(' I ,O. td Date: 5- (�-- I <br /> Address: 2-87L/ M/A'sburUr /VG- Phone:. 5 /-T]9'-0I18 <br /> City,State,Zip 4/bail 012. 9 7 32-1 Fax: <br /> E-mail Address 9u Vi n-erhe)( o Vn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> Company Name: Bethel Excavating <br /> Signature: Date: <br /> Address: PO Box 504 Phone: 503-743-2343 <br /> City, State,Zip Turner, OR 97392 Fax: 503-743-3638 <br /> E-mail Address officeabethelexc.com <br /> DEQ License# 36198 CCB# 44551 <br /> G:IFORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />