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aq-awo <br /> �► ,,i�i11+ 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://www.co.marion.or.as/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Sean Dugger ,have authorized <br /> (Property Owner I Print Name) <br /> Herbert 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 /> o//(33 ,p pro'o? /,J (yobs <br /> • Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description SEC 18 TWN 09S RNG 03E Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: Sean Dugger <br /> Signature: 6,a,�Q-��P Y Date: 08/09/2024 <br /> Address: C�J Phone: <br /> City,State,Zip Fax: <br /> E-mail Address Axiumconst@yahoo.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Herbert C Wilson, Jr <br /> Company Name: Lone Pine Corner Septics,ic Inc <br /> Signature: .G/ .�r C� f � Date: <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 & RI-100 CCB# 177063 <br /> G:IFORMSISEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />