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MARION COUNTY BUILDING INSPECTION DIVISION JAN 14 1021 <br /> _--- 5155 Silverton Rd NE <br /> MARION 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: \ " — a1Ea\ MCBI File#: jr- Li 000go' <br /> SECTION 1—APPLICANT INFORMATION <br /> 1. Property Address: cg5D eft if" SA- 1v Property ID#: \C>S E(D\ Pg_- LICE <br /> Section: Township: Range: Tax Lot#: <br /> 2. Name of Applicant: 1 fie\ LX(p,,Up,i1 j1fl� Telephone#: O "1L1� a.b.k <br /> Mailing Address: 'Ie3QY � �`1 eckILLV 'v 1ej(C.CONI <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> Single Family Residence <br /> 0 Business <br /> Cl Other: <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> O New Installation Permit <br /> Repair Permit 12Q0a(Q qAvir OrN-TO0d`'1-- Or\v. <br /> ❑ Alteration Permit for: ❑ Replacement Dwelling 0 Bedroom(s)addition <br /> O Other changes in land use involving potential sewage flow increase: <br /> G:\FORMS\S£PTIC\Application Packets\S-39 LUCS.doc MC:S-39 rev:8/10,04/12 <br />