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- - - <br /> �, MARION COUNTY PUBLIC WORKS <br /> til ��'''�-qii i <br /> BUILDING INSPECTION DIVISION <br /> • <br /> ��-��= 5155 Silverton Rd NE <br /> ® c-Eilv . 0 <br /> -. .. ,.; : Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> i ;.. Y. http://www.co.marion.onus/iW/Buildinglnspection MAY 0 2 2019 <br /> ' <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTfCE AUTH RUZlNG i''EPRESENTATIIVE <br /> Caf��' ,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 /> P Is OPERTY IDENTIFICATION: <br /> e <br /> 'IL& ) f <br /> PrArty Situs or Street Address <br /> And described in the records of MARION County as: .. <br /> Legal Description NAI ev ay) my Z Tax Lot#(s) af' 3 $> 137, ' <br /> PROPERTY OWNE": <br /> Printed Name: I (-7 dtc,s i <br /> �] Date: 67//y <br /> Signature: \J � -��-��, <br /> Address: Pe Q,")..., 37> Phone: ,cD 3-S•71- 3 Oa 2 <br /> City, State,Zip ,S7,16 - C1-. '73 a'% Fax: <br /> E-mail Address hLr C'�-p..¢ j MAI/ i e_orrr+ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: HERBERT C WILSON, JR <br /> Company Name: LONE PINE CORNER SEPTICS, INC <br /> w <br /> Signature: `, 1 1 "C till . :Date: <br /> Address: 8778 CASCADE H\NY 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 CCB# 177063 <br /> G.IFORMS\SEPTIC1S-07 Auth to Apply doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />