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MARION COUNTY PUBLIC WORKS <br /> , _• BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)538-5147 Fax(503)583-7948 <br /> 14http://www.eo.marion.or.usfPW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> / o" <br /> 1> `trr`1 I : • rt t t..3 _._ ____.._.....___..___............_...._..__._____..,have authorized <br /> (Property Owner I Print Name) <br /> Herbert <br /> inc to act as my agent in performing the <br /> vihYsan,.!r tt+ane Pine Gamer Seplics, <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/..t, otc 9737c <br /> Property Situs orStreet Address <br /> And described in the records of MARION County as: <br /> Legal Description_..U. a_-- -° 4( Tax Lot it(s)__ � �:. ..._............................. <br /> PROPERTY OWNER: <br /> Printed Name: 1 ,1214.41,e _ <br /> Signature: f - ! � Date:— i <br /> Address:..: I Wit,�g Phone: c's _jr3. <br /> City,State,Zip ;5% ,--F -, Fax: <br /> E-mail Address._. -tra-24 lu,,.a L.3.... 1,-ne <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Herbert C Wilson,Jr <br /> Company Name: Lone Pine Corner Septics, Inc <br /> Signature: ,.r 'G� 7, A,Ze Date: <br /> Address; 8778 Cascade Hwy NE phone:503-873-7157 <br /> City,State,ZipSilverton, OR 97381 p„:503-873-5562 <br /> E-mail Address LonePineSeptics8778@gmaiLaom <br /> DEQ License l 37003& RI-100 CCB# 177063 <br /> di S'ORT,lskel l rlc S-L7 AoNl;31,Apply.dvc <br /> MCS 07 Rev 03+10 <br /> SEPTIC. 4 <br />