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•dli' .`'�,ry,,,„i��1 MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> �—� xi 5155 Silverton Rd NE <br /> iiii..- � Salem OR 97305 • <br /> (503)588-5147 Fax(503)588-7948 <br /> bttp:/iwww.co.marion.or.ns/PW/BuilclingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, L)t di 1) 119 Jb f_yezr-c 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 /> PROPERTY IDENTIFICATION: <br /> a tile 6i Li/E-1 Ai Or 973 8/ <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: ,/ <br /> Legal Description Tax Lot 4(s) 0%4-3 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: P6 i/,D 5.6 = I ff <br /> Signature: i ) • J Date: "I/2 b/. v"L0-- <br /> Address: J S 7 31- G�l-T dR 4/ Phone: 5�.5�'777J`73--4ve-Y- <br /> City, State,Zip _�.i(va.r- r O7 9.73V Fax: <br /> E-mail Address clbe r'eka,Fe-0 ,Li✓ -; c.e,vn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Herbert C. Wilson, Jr. <br /> Company Name: Lone Pine Corner Septics, Inc. <br /> Signature: \arJAPA J1 Date: ;va D a a <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.pmail.com <br /> DEQ License# 37003 R-1-100 CCB# 177063 <br /> G:IFORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />