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DocuSign,l=nvelope ID:BFB5E381-2EE6-403E-9AF3-3078667814:96 <br /> MARION COUNTY PUBLIC WORKS <br /> Alt tl . ''` BUDDING INSPECTION DIVISION <br /> • <br /> 5155 Siiverton Rd NE <br /> - Salem OR 99305 <br /> (503) 588-5147 Fax (503)588-7948 <br /> ..� • http://www.ce.mationAr.us/P131/Buildinginspection <br /> NOTICE AUTHORIZING REPRESENTATNE <br /> T, } e-1�.►r\ t t, T S TT , 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 /> v cv r>_y4.0 9_g I"J cb p <br /> i=}(;1`� , :'1!., c.I-1 S S b,. — <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) '�.l y44 <br /> PRQPERTY OWNER. <br /> Printed Name ���l " 'I <br /> Signature: / / � Date: Via.- <br /> Address: /7/ ? - `-�� �� Phone:, �3 2�•,'? `�`'�.__ <br /> City, State, Zip a` \ems Qg 3 - Fax: <br /> E-mail Address 01 , _C)3 — /471•69 h <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: HERBERT C WILSON, JR <br /> Company Naarte: LONE PINE CORNER SEPTICS, INC • <br /> Signature iAC� _ Date: <br /> Address: 8778 CASCADE HWY NG.._ Phoii::503-87307157 <br /> City, State, zip SILVERTON, OR 97381 Fa. :5O3--873-55562 <br /> E-mail AddressLonePineSepticS8778Qgmail.cogrt <br /> DEQ License# 37©03 _ CCB # 177063 - <br /> 0:\FORMSESEPTtC1S-07 Auth to Apply.doc o <br /> MCS-07 Rev 03/10 Z rt� e <br /> SEPTIC : i. ., <br /> J ,; "", 5/28/2020 1 3:00:55 PM P*/28/2020 1 7:35:28 PM PDT <br />