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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 4L <br /> 5155 Silverton Rd NE <br /> EXP <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503)588-7948 <br /> 7948 1RED <br /> http://www.co.marlon.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> LOYkO A. 'e.,1/4.1 ton ,p have authorized <br /> (Property Owner/1*int 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 /> 953s EAkt‘f3Z L6e eA,\R 1-.toys 0 7 b <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description tiogp Og Z£.O 1..UC b O6-OC) Tax Lot#(s) k(' , 100 R L(( 3 3 4 <br /> Subdivision,Lot and Block <br /> Code Ia.9voockC7 <br /> PROPERTY OWNER: <br /> Printed Name: L p cF Jo R\e.,,i,001 <br /> Signature: �� Date: Li —2 3 aO <br /> Address:1-/D2Y S Phone: Co 3 - 6 7 0 - 9 d <br /> City, State, Zip S i',.t2 , Q ! 7 30 Fax: <br /> E-mail Address CL.(A.tel.Eko & p Q Aoki ( • ( 'A <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Herbert C. Wilson, Jr. <br /> Company Name: Lone Pine Corner Septics, Inc. <br /> Signature , ) Q.---- — Date: II"a 9 " <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 LonePineSeptics8778agmail.com <br /> DEQ License# 37003 R-I-1 00 CCB # 177063 <br /> G:IFORMS\SEPTIC1S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />