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DocuSign Envelope ID:D7E539A4-9205-4222-94FE-85188C00BB4B <br /> N. <br /> MARION COUNTY PUBLIC WORKS <br /> ill BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.mari on.or.us/P W/Buildinglnspection <br /> ,7 NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, G1ferid% 7Cae//iii S., rUcfnio r iyyi;ice ,,l€c5o,2 T4:e!! 7i6/.5 ve authorized. <br /> (Property Owner/Print Name) <br /> Lee Bethel-Bethel Excavating I to act as.my agent in performing the <br /> (Authorized Representative/Print Narce) <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 /> cob/D ,B,e:9�.: e, Q d, 5<<re eri? CI,( 97,9 / <br /> Property Si s or Street Address <br /> Described in the records of MARION County : <br /> Legal Description Tax Lot#(s)_ 33 3 9C3 <br /> Subdivision,Lot and B ock <br /> PROPERTY OWNER: <br /> Printed Name: &dtivi1L�vs oraerj1/ii7 S .�17Q1/' e.e-) /9�/Y!/;l fo-7LC!/Y1%(� <br /> Signature: wUAJA G I .wLiv,S I Vbt,Sft t. I 6/17/'iZ4 <br /> �AUiaunrnrfeeaFr,... Date: <br /> Address: PO Box 125 <br /> Phone: <br /> City, State,Zip Powell Butte, OR 97753 <br /> _. Fax: <br /> E-mail Address _GUe (kle gate/ff 115. 07(.3 MQ14C'0'/Yl <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel <br /> Company Name: Bethel Excavating <br /> • <br /> Signature: 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 of ice@bethelexc.com <br /> DEQ License#. 36198 I CCB# 44551 <br /> G:IFORMSISEPTIC1S-07 AU1'H TO APPLY.DOCX Rev 3/10,3/18 <br />