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<br /> MARION COUNTY PUBLIC WORKS 1 1C --E {
<br /> g,:4.4'41111,1(.•
<br /> • i: BUILDING INSPECTION DIVISION
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<br /> --i•;;T:-- -.-.. '.,_.:•-%-,..z..........v 5155 Silverton Rd NE "I LI OCT o 8 2021 L--ii
<br /> rftii,T441 Salem OR 97305
<br /> (503)538-5147 Fax(503)588-7948
<br /> http://www.co.raarion.or.usfPW/BuildingInspection
<br /> MIN MARION COUNTY
<br /> BUILDING INSPECTION
<br /> NOTICE AIJMORIZING REPRESENTATIVE
<br /> I, ,.\ C n.04,-4\-a-Pt fi- - lz_-_,' have authorized
<br /> (Property Own'eF/Print Name)
<br /> Herbert C. Wilson, Jr. & Lone Pine Corner Septic,s, Inc. to act as my agent in performing the
<br /> (Authorized Representathie/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 IDENITFICATION:
<br /> 9S-60S— 1-31140-n. lti(No h CZ . A) r L , op 97$sy
<br /> Property Situs or Street Addrer I •
<br /> Described in the records of MARION County as:
<br /> Legal Description - Tax Lot 4(s) O
<br /> Subdivision,Lot and Block
<br /> PROPERTY OWNER:
<br /> Printed Name --)"'ft e'•'.414,,, A, r' /-4- m- LA-)'e,si-
<br /> Signature: - Date: /0,4Y12,0 2/
<br /> Address: 7y s-s9 Re41,,..,2,,,‘„, ,9-,rj E Phone: 3-0 -3.90-oaciv
<br /> City,State,Zip K•e,,-;cA.r-, 0 p. 1 7.50,g. Fax:
<br /> • E-mail Address e,r-f—
<br /> AUTHORIZED REPRESENTATIVE:
<br /> Printed Name: Herbert C. Wilson, Jr.
<br /> Company Name: Lone Pine Corner Septics, Inc.
<br /> Sigtature: 1..#1ditN. C tX1 aaktOi IA •Date:I b:1.1 *k 34
<br /> Address: 8778 Cascade.Hwy. NE. Phone: 503 -873- 7157
<br /> City,State,Zip. Silverton, OFR 97381 Fax: 503-873 -55.62
<br /> E-mail Address LonePineSeptics87780qmail.coni
<br /> DEQ License.# 37003 RI-1 00 • CCB# 177063
<br /> G:TORLMS1SEPTICAS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 • .
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