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n <br /> r \ <br /> 140 o 2 2022 <br /> °���,,,,r RECM.VEn <br /> M RION COUNTY PUBLIC WORKS ,� <br /> BUILDING INVECTION DIVISION <br /> ...—i��1ti 555 Court St.NE Room 2260/PO Box 14500 <br /> BUILDING INSPECTION <br /> '' ''� Y- Salem OR 97309-5036 <br /> ��:.,tea <br /> (503)588-5147- Fax(503)588-7948 <br /> http:Upublicc�orks.co.marion.orus/bailding� <br /> y l'illrillIl <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> tfri9 A►Er jam, 13 a t5 $14 ,have authorized <br /> (Property Own /Print Name) <br /> T. P i n P C.01-n F•r R¢pi'i r c Tn r_ - to act as my agent in performing the <br /> 1, (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 IDENT-t e.CATION: . <br /> 1p75 3 JRat,: , 1�.0�- A 0 9 I, 5 <br /> • roperty Silus or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) R 3 03 <br /> PROPERTY OWNER: <br /> Printed Name: tT f iii GT t o 13 u J 8. - - <br /> Signature: (J( ofp ifiway Date: 10- 3 j —.�ZUA a. <br /> Address: 414.4ifilerwi XI- go•1.3%i 4,44 Phone: , O3._.747•-a 19%t <br /> City,State,Zip - - ' 91.3 Fax:E-mail Address Twat` - 34 3 d <br /> . AUTHORIZED REPRESENTATIVE: <br /> PrintedNaine: iipr TIP rt C. Wi l son Jr, - <br /> Company Name: Lone Pine Corner-S et)tics Inc. - <br /> Signature: j '� 1-AJOU.III Date: - <br /> Address: 8778 Cascade Airy NE- Phone: 503-873-7157 <br /> City, State,Zip Silverton, Or. 97381 • Fax: 503-873-5562 _ <br /> E-mail Address 10 nepineseptics-.. . _- _ <br /> DEQ License AI. 37003 & RI-100 CCB# 177063 <br /> G:1FORMS SEPTICI.S-07 Auth to Appiy.doc • <br /> MCS-07 Rev 03/07 <br /> SEPTIC• 4 <br />