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5195 I <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> • 5155 Silverton Rd NE /] @� <br /> Salem OR 97305 ® - 7 �/ <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Building1ns c on MAY 0 2 2019 J <br /> MARION COUNTY <br /> J <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, /eK,7 ellYer <br /> have authorized `Qs <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 /> __ CAr rev-4w- <br /> ti <br /> id 1,5 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description )1u,l CrI) O-) Tax Lot#(s) ee.3 $' P.7 <br /> PROPERTY OWNER: <br /> Printed Name: ' t 42(7 1-e-,-- <br /> Date: s-// <br /> Signature: � �-e�C�s // <br /> Address: ,9 3 7> Phone: ;TO 3^ 77- 3e)400 <br /> � n � <br /> City, State,Zip J fi'l / -. ?732/ Fax: <br /> E-mail Address N C''0 04 f MIA%f # el#T7A3 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: HERBERT C WILSON, JR <br /> Company Name LONE PINE CORNER SEPTICS, INC - <br /> Signature: ,,:1,r`1_. i 1 Date: <br /> Address: 8778 CASCADE HWY NE r 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 CCB# 177063 <br /> G\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />