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������,,,���` MARION COUNTY PUBLIC WORKS <br /> ,III "'�� BUILDING INSPECTION DIVISIO N <br /> =%`� 55155 Silverton Rd NE <br /> Salem7 OR 9 305 • <br /> (503)588-5147 Fax(503)588-7948 <br /> http://.www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, C-1\E I I 1-i 1( IM711 jltt 5 ��►i-L 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 /> I�500 in+ P ) / I ( A 115 J�.4 SCD -S n9 l b M C 7 <br /> Property Situs 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: <br /> Printed Name?fl fl( S 1.4, CJ\€r L L It c6t _ <br /> -13 Signature: CE J Date: �� A I <br /> Address: 1 e e/ / ®`I 1 1( 1 In , <br /> Phone: �j() 9-0 <br /> City, State,ZipSC j) 5 h i i 1G ()E ci r7,37.c Fax: 603 .27 3- p <br /> E-mail Address Oivei-t i 1 LRILL...14-c • <br /> • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Herbert C. Wilson, Jr. <br /> Company Name: Lone Pine Corner gSeptics, Inc. <br /> • <br /> Signature: �••i,�c,,,A '� a . I,✓14.6+N Date: 5^ 3 - 2 O 75 <br /> Address: 8778 Cascade Hwy. NE. _ <br /> Phone: 503 873 - 7157 <br /> City, State,Zip. Silverton, OR 97381 Fax: 503- 873 -5562 <br /> E-mail Address` LonePineSeptics8778@gmail.corn <br /> DEQ License# 37003 R-I-1 00 CCB4 177063 <br /> GAFORMSISEPTICIS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />