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1 <br /> ijl -bOd667_,n,),t_, <br /> "' *►° �� MARION COUNTY BUILDING INSPECTIO SIk* ON <br /> --=%--": 5155 Silverton Rd NE ''' JAN 23 2021 <br /> am <br /> Salem OR 97305 <br /> (503)588-5147 hfii-tir" 4ON COUN�r <br /> Fax: (503)588-7948 BU�L(711VG INSPECTION <br /> LAND USE COMPATIBILITY STATEMENT(LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: 1/ a 5lao� ( MCBI File#: <br /> SECTION 1—APPLICANT INFORMATION <br /> 1. Property Address: 131 LI)(,I j 5(4 Si" Property ID#: <br /> (1a`f e s, Op)? 1 St4 t.. <br /> Section: Township: Range: Tax Lot#: <br /> 2. Name of Applicant: NI.rYQ( (A.S 4 Telephone#: <br /> Mailing Address: .*6,Iv1/4e, CLA, a ait_. <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> 6-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 /> Ci:\FORMS\SEPTIC\Application Packets\S-39 LUCS.doc MC:S-39 rev:8/10,04/12 <br />