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• <br /> ova --Pgm s <br /> ad , <br /> ,+. MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING_ INSPECTION DIVISION <br /> - ~��1��- MAY 082024 <br /> �� ` � 5155 Silverton Rd NE <br /> Ill.j.j <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.onns/PW/BuildingInspeetion <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> L Lei i /' A Re-kJ k)(1)tb, have authorized <br /> Herbert C. (Property Owner' l rintName) <br /> Wilson, Jr. & Lone Pine Corner Septics, Inc. to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> • <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 /> Q53S alk- IO tZ (114.. SE_ ktdoys Ok. <173b-0 <br /> Property Situs or Street Address . " l <br /> Described in the records of MARION County as: <br /> Legal Description Nlizirp Og 3 L D AI_bOs'b0 Tax Lot 4/(s) (',, © ?'{(3 3 4 <br /> - Subdivision,Lot and Block <br /> Code.. 128(9004 6 - <br /> • <br /> PROPERTY OWNER: <br /> Printed Name: LO A- fot)[44 <br /> Signature: ' 1. <br /> nYc)(� Date: 5 --�'--Z I _ <br /> Address:LI0a s A)e...., Phone: 4 p$ - 6 7 0 - q q/c1 <br /> City, State,Zip St4_1c„,r I e 1 7 30 Fax: <br /> E-mail-Address QL A.--1-e1 le..6:A o' .Cp ( . €!ivv'. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Herbert C. Wilson, Jr. <br /> _ Company Name: Lone Pine Corner Septics, Inc. <br /> Signature c-----_ , ---- - Date: ‘5 —!¢ 2� <br /> 1 <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 LonePineSeptics87780gmail.com <br /> DEQ License# 37003 R-I-100 CCB# 177063 <br /> G:1FORMSSSEP1TC1S-07 AUTH TOAPPLY.DOCRRev 3/10,3/18 <br />