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/9'- &o&& <br /> �n 4 'imzt, MARION COUNTY PUBLIC WORKS <br /> 1 UILjIINO INSPECTION DIVISION <br /> .7.- ----�s =- • 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> _-- ht'ttpllwww,Co.matron.or.ns/PW/BuuldingInspeetion <br /> NOTICE ,A UTA IROZONG REPRESENTATIVE <br /> 1CsZ �c� e <br /> 22 ,have authorized <br /> (Property Owner/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 /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legai`DescriptionP Tax:Lot#(s) <br /> P OPE.'TY-OWNER: <br /> Printed Name: <br /> + Si atei ". 01,17eV . Date: 3/Z6-7/7Address: 11 o9 y -1 1 s_1 A'-c Phone: <br /> City, State,Zip SC.1 e--i--e) r-" ci-7 SOS Fax: <br /> E-mail Address <br /> ATUT. O i✓_;1l)REPRESENTATIVE: <br /> Printed Name: Herbert C Wilson, Jr <br /> Company Name: Lone Pine Corner Septics, Inc <br /> Signature: / '_ C-' /. _rv„,,-- .72-7 Date: <br /> Address: 8778 Cascade Hwy NE -7— A e:503-873-717 <br /> lianb. <br /> City,State,Zip Silverton, OR 97381 Fax:503-873-5562 <br /> E-mail Address LonePineSeptics8778 a@gmail.corn <br /> DEQ License# 37003 & R1-100 CCB# 177063 <br /> G_IFORMSISEPTICtS-07 Auth to apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC .' 4 <br />