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�'�� MARION COUNTY PUBLIC WORKS <br /> ,iii 1j��iiii''ue BUILDING INSPECTION DIVISION <br /> ��7 -1 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> mii <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, CAA ei e e 1 V01 ill i elir41 " 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 /> 760 Urortit I,ie_1...i *lee_ J 4 ." Al,'Ili' 0e <br /> Property S�itus or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER:Printed Name: ® i.e,1 s I I e 0%,fr-if <br /> Signature: _ Date: <br /> Address: 0 9 rR v i e_'LI Phone: 7/-7/ 8^ 8 7/ <br /> City, State,Zip. ,. d evil%Ili', 0 e Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel <br /> Company Name: Bethel Excavating <br /> Signature: 24L 6 Date: <br /> Address: PO Box 504-69 6 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:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br /> , <br />