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ti <br /> --es ()Ca E-4/4C).1 / <br /> MARION COUNTY BUILDING INSPECTIO I�ISIO <br /> 5155 Silverton Rd NE J <br /> Salem OR 97305 JAN 1 2 2021 J <br /> (503)588-5147 <br /> Fax: (503) 588-7948 MA IUN COUNTY <br /> BUILDING INSPECTION <br /> LAND USE COMPATIBILITY STATEMENT(LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS - <br /> DATE: i�11�''D MCBI File#: <br /> SECTION 1—APPLICANT INFORMATION <br /> 1. Property Address: S b b►7 1-`.,' w o o d '(3 r Property ID#: <br /> —a < 2 34 b G ZD <br /> C' tS � 4� 3 <br /> 5� 3E � CD v a <br /> Section: Township: Range: Tax Lot#: <br /> 2. Name of Applicant: 'f-o•nk INAV e iOnq 1 r1 bSko4 Telephone#: <br /> Mailing Address: aS!b l4"c vc SG <br /> ga�e� ek 97 317 <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 />