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\----; <br /> RION't, <br /> „, Co UNTY FOLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> �` �ti <br /> mT • _•� .•A 5155 Silverton Rd NE <br /> au Salem 0R97305 <br /> (503)588 5147 Fax(503)588-7948 <br /> http://wmeo.marion.or.us/PW/Buildingtispeetion <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, tktla 1.AG-r:,r7-ore /4itt010 S1444S MAlek tIC have authorized <br /> (Property Owner/Print Name). <br /> Herbert C.Wilson,Jr. &Lone Pine Corner Septic.,inc. to act as my agent in performing the <br /> (Authorized Represcntatj /Punt 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 IDENT;FICAfON: <br /> (e?'S to 405 sr' se 51:Iso ') 04 9'7s17 <br /> Property Sites or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description__C2S"./W. Co Its s. Tax Lot s) 5'ac( (p34 <br /> Subdivision,Lot and Block -- <br /> PROPERTY OWNER: <br /> Printed Name: hi a 444rJr OF �40/iimmie SPIj4s£4limi£LC <br /> Signature: 5d!43 <br /> .address: $/2� 1'✓/ Date: <br /> G 4NE N Phone:_SQ3_3ip I g 3� <br /> Cam,state, 13Ig ZTe -.,73.1z Fax: 5b3 39G (ozo 3 <br /> Einailmaress &Am AN9 1< rr-(a lit �0�p7eo./1 7- _ <br /> nuTHORIZED REPRESENTATIVE: <br /> Printed Name: Herbert C.Wilson,Jr <br /> Company Name• Lone Pine Corner 5e tics,Inc. <br /> Signature:A1 C,lUa'Syx Date 1 1 .'�,"3 w <br /> Address: 877e cascade Hwy.NE. .,-- <br /> Phone: 503-873-7157 <br /> City,State,Zip Silverton,OR 97381 Fax: 503-873-5562 <br /> E-mail Address LonePineSe tics8778 mallcom <br /> DEQ License# 37003 R-I-100 CCB# 177083 <br /> aaroRMstisaprias.07 ntrrxTo aPpr.Y_noCCReV ano,ens <br />