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°'' '' 1 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 �ad MCBI File#: 2-0 7d rat -Pate- <br /> SECTION 1 —APPLICANT INFORMATION <br /> 1. Property Address: 7 0 3 Property ID#: Ot4Q ( C,12) <br /> 560-1--\-5 ;\b ©ve. v573 <br /> Section: Township: Range: oTa of#: <br /> 2. Name of Applicant: T�g 7:63-12.?A 5)tic,k Telephone#: - 700 <br /> Mailing Address: 101�5'- 3)1' Ave— AAA/ <br /> \ern G C_ q"13 0 <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 />