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/CT-oozzo9- ?ApIT <br /> �����,,,, MARION COUNTY PUBLIC WORKS J _ <br /> '����''" ""'�' � BUILDING INSPECTION DIVISION ® �, <br /> --a -------- --1."----: <br /> MI <br /> 555 Court St NE Room 2260/PO Box 14500 <br /> .4.------:-.......:;,..7...-:...1-7- Salem OR 97309 5036 <br /> (503)588-5147_ Fax(503)588-7948 MAR 6 20�9 La. <br /> http://publicworlis.co.marion.or.us/buiiding/ MARION COUNTY • <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE • <br /> 4 I, GI-er\ is • .V n€* ,have authorized • <br /> (Property Owner/Print Name)e) _ <br /> T.nnP Pine Corner SPptirs Tnr_ - . 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. - b <br /> PROPERTY IDENTIFICATION: . <br /> '1,21, )ex„,1 Sk `tee Au 'i d l l.e.k Q ki ,. q3 .' <br /> - Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description - Tax Lot#(s) <br /> PROPERTY OWNER: <br /> • <br /> X PrintedNam-�! /e,1 1• \V r r - - <br /> 4 / • �r <br /> Signature. , — ,I-i Date: ?j- l 8-)9 <br /> Address: 12 L 5 5 X eca -V S-E Phone: 70 3 - 7 4 9-- 7 7"tii <br /> City, State,Zip IAV Nn., 4 1-t ke., Q 2 `73'Ds- Fax: <br /> E-mail Address bu rrnecj @ Ao L .C..6 <br /> AUTHORIZED REPRESENTATIVE: - . <br /> Printed Name: Aerhert C.. Wil con .Tr, <br /> CompanyName: .Lone Pine Corn//er Septics Inc. <br /> . Signature: 74/,,,,t e, /4)_, .,.., ,-/ Date: 31/S/ of t?/ - <br /> Address: - 8778 Cascade Hwy NE. Phone: . 503-873-7157 <br /> City,State,Zip Silverton, Or. 97381 - Fax: 503==1 -37 ;.r61; gal, _ <br /> E-mail Address lone pine septics $7783 G HAIL , Cow, - - <br /> DEQLicense# 37003 & RI-100 CCB# 177063 <br /> G:1FORMSISEPTICIS-07 Auth to Apply.doc • <br /> • <br /> MCS-07 Rev 03/07 <br /> SEPTIC' - 4 <br />