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MARION COUNTY BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 <br /> Fax: (503) 588-7948 <br /> LAND USE COMPATIBILITY STATEMENT (LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: 10- - 2-v MCBI File#:2° a°77-?2? — 4e'T_ v <br /> SECTION 1 -APPLICANT INFORMATION <br /> 1. Property Address: apapck --krk.,.Joov NL Property ID#: <br /> Section: Township: Range: E)(Tax IR R E D <br /> 2. Name of Applicant: jc.otC. „) Con 1)rt..`_ Telephone#: 9)2- 5<IQ V <br /> Mailing Address: 0 . so4. c t1 <br /> cr‘. D2- /.7( o <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> Q4Single 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 /> Iti510,6% -Rep ` tip►N 2ro J . <br /> G:\FORMS\SEPTIC\Application Packets\S-39 LUCS.doc MC: S-39 rev: 8/10,04/12 <br />