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MARION COUNTY PUBLIC WORKS D E C E I V LE <br /> 17. BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> I I F'1t' 0 � 2093 <br /> 11111 Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> hfp:/Jwuw.co,marrion.or,usIPW/$uiidingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I: �1 W tr-r eare4 t 'fntt or' Dginive,SPOIN4s ANNUL 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 tii•e ary 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 /> Lt 1-'3-4 -105 S7- s E vli.rxm, o2 g 7'3/7 <br /> (� Lei Q Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Q gR W t.HOC) Tax Lot#(s) `j Lo SO' <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER:Printed Name h1 fl1SNSG Sivr OF f4ifl rD 5PE/45 Se4A )J G CC <br /> Signature: -/ Date: `10l 712 r <br /> Address: 5725- h(f77'E rigI- /V 4NE Phone: S:p3 ate 1I 34 <br /> City,State,Zip f ciz f 6I q'Z36 Fax: 503 39G (eZo <br /> E-mail Address TFAm 41/094Z ''' 'i t Sr Dar/cc.NET- <br /> AUTHORIZED REPRESENTATIVE: <br /> PrintedName: Herbert C.Wilson,Jr_ <br /> Company Name: Lone Pine Corner Septics, Inc. <br /> Signature: 4 n tiQ 4. Date:1/-//7 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@gmaii.com <br /> DEQ License# 37003 R-I-100 CCB 1 177083 <br /> O;WORM512EP"11C1.5.07 ROTH TO APPLYJ)OCX Rao 3/10,3/18 <br />