Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http:/iwww.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, f\rA -bc,0,4 have authorized <br /> (Property Owner/Print Name) <br /> Herbert C. Wilson, Jr. & Lone Pine Corner Septics, Inc. 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 /> 1345 CA-5cacei Uw N 51 vvic7 n .773g l <br /> • Prdperty Situs or Street Address • <br /> Described in the records of MARION County as: <br /> Legal Description 0 6 iv as C. • Tax Lot#(s) 02 0 f3 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> • Printed Name: !�t'T 10 e7 6.IA r 1 <br /> Signature: Date: 1k 6 t 1- <br /> Address: LA 3 CA 5�, D ' Phone: E' L- `c 1-2 ` - <br /> City, State,Zip S1kv Uo . 1.� 'l 3 t. Fax: <br /> E-mail Address iv\GO aj�t 5, S ( (P1. '�v �t lam. , �)d' , <br /> mgll f'1s 4.Dpress ; P. 0 ,13o7 l7 SI I✓�✓'[ a <br /> AUTHORIZED REPRESENTATIVE: l ) 1158 , <br /> Printed Name: Herbert C. Wilson, Jr. <br /> Company Name: Lone Pine Corner Septics, Inc. <br /> Signature: W %ASti5 Date:I Q— q <br /> Address: 8778 Cascade Hwy. NE. Phone: 503 - 873 - 7157 <br /> City, State, Zip. Silverton, OR 97381 Fax: 503- 873 - 5562 <br /> E-mail Address LonePineSeptics8778@gmail.com . <br /> DEQ License# 37003 R-I-100 CCB# 177063 <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br /> • <br />