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MARION COUNTY PUBLIC WORKS <br /> "111 "' BUILDING INSPECTION DIVISION <br /> 5155SilvertonRdNE RECEIVED 1 <br /> inewing Salem OR 9'1305 <br /> - <br /> (503)588-5147 Fax(503)588-7948 MAR g 9 $ <br /> MEM <br /> http://www.co.marion.or.us/PW/Buildinglnspection2024 <br /> i • <br /> NOTICE AUTHORIZING REPRESENTATIVE ° <br /> �l�-;'� Vidc.-.-:—.A,u)�� have authoriz� <br /> I, { <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 evalm lions,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 IIDEN Jii 1CATION: <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description • Tax Lot 4(s) • . <br /> Subdivision,Lot and Block <br /> `f <br /> PROPERTY•OWNER: • <br /> Printed Name: A J .) • <br /> Signature: Date: S@ VA <br /> Address: co e�6`(-.. dad Phone: <br /> -3 930 t2B <br /> City,State,Zip I ' L 1 b -737- Fax: Nil\ <br /> E-mail Address lirLANi i Mi CS &L iv c •C3JV <br /> . <br /> AUTHORIZED REPRESENTATIVE: - <br /> S <br /> Printed Name: Lee Bethel <br /> Company Name: Bethel Excavating <br /> Signature: OA a Date: 3 igia.ti <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 /> • <br /> I G:�FORiNIS1SEPTIC1S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />