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` =. :td <br /> MARION COUNTY BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd-NE <br /> Salem OR 97305 <br /> (503) 588-5147 - ® ECEIIVE Fag: (503) 588-7948 <br /> JAN 2 5 2019- <br /> 'ARI ®�� <br /> BUILDINC3I�6GINSP <br /> LAND USE COMPATIBILITY STATEMENT(LUGS) �G�-I®A, <br /> FOR ON-SITE SEWAGE SYSTEMS 19-0r406,1(7 <br /> • <br /> DATE: MCBI File#: • <br /> SECTION 1—APPLICANT INFORMATION <br /> 1. Property Address: t 1 a`il G krov- s Property ID#: <br /> Section: Township: Range: Tax Lot#: <br /> • <br /> 2. Name of Applicant: A`(\ e1a � I C Telephone#: 503 302 <br /> . � to st <br /> Mailing Address: • 5\ �o��e S �r 1, <br /> • a. <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> ❑Single Family Residence <br /> yI <br /> Business - <br /> ❑Other: • <br /> • <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> ❑New Installation Permit <br /> ❑Repair Permit <br /> U Alteration Permit for: ❑Replacement Dwelling ❑Bedroom(s)addition <br /> MOther changes in land use involving potential sewage flow increase: <br /> • <br /> . GAFORMS\SEPTIC\S-39 LUCS.DOCX Rev:8/10,04/12,03/18 <br />