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ECEHIVE <br /> 12/ <br /> -n-- NOV 1 7 2021 <br /> MARION COUNTY BUILDING INSPECTION DIVISION <br /> .dinfrANiy�,aauc <br /> 5155 Silverton Rd NE MA .OV COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503) 588-5147 <br /> Fax: (503) 588-7948 <br /> LAND USE COMPATIBILITY STATEMENT (LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: /0 JA It's MCBI File#: <br /> SECTION 1-APPLICANT INFORMATION <br /> 1. Property Address: rss-��ni Ct Property ID#: <br /> Section: Township: Range: Tax Lot#: <br /> 2. Name of Applicant: /14,J C /1. Telephone#: Srb 3 - - G 0 3 y <br /> Mailing Address: 3 A 4' <br /> S1/4 .2 , o , >> <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> Single Family Residence <br /> ❑ Business <br /> ❑ Other: <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> New Installation Permit <br /> ❑ Repair Permit <br /> ❑ Alteration Permit for: ❑ Replacement Dwelling ❑ Bedroom(s)addition <br /> ❑ Other changes in land use involving potential sewage flow increase: <br /> G:\FORMS\SEPTIC\Application Packets\S-39 LUCS.doc MC:S-39 rev:8/10,04/12 <br />