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ION COUNTY BUILDING'INSPECTION DIVISION <br /> L30 <br /> Salem.+ 9?34S <br /> • <br /> :{ 03)555142 • <br /> • FaX ( 03)" 8 -7948 <br /> • .Lam"USE•COMPATIBILITY 'A' 'E 'I pa <br /> • FOR ON-SITE SEWAGE SYSTEMS <br /> :'F <br /> a DATE x <br /> r . <br /> SECTIO1s11.•-APPLICANT.INFORMATIOH+1;. :: <br /> 1. Property Address:�. � `, `Property II? : <br /> - Section: • Township: Range:. Tax Lot# <br /> 2. :Name of Applicant C© - Telephone 5c 3 O 4O t"" <br /> Mailing Address 4 , ,, D\ <br /> • 37 , <br /> m .: <br /> 3 Descriibe"type of facility•the sewage"system will e sery (business esidence or-other): <br /> • 'Single•Family Residence <br /> C7 Business <br /> 0 Other <br /> 4 Type of on site•sewage system permit application being proposed for this property <br /> ew Installation:Permit <br /> Repair permit <br /> CI Alteration.Permit for ❑ ReplacementDwelling D Bedrooni(s)"addition <br /> . ,C!-other chan•ges inland use.involving potential sewage flow increase: • <br /> • p <br />