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tit <br /> Form 2920.1 <br /> q al)) FORM APPAOVFDOMB <br /> UNITED STATES NO.?.uu-3002 20 <br /> DEPARTMENT OF THE INTERIOR FOR watavorl,xw wWnmaxrlu-vn use mi5 <br /> BUREAU OF LAND MANAGEMENT <br /> LAND USE APPLICATION AND PERMIT ApplicatianNumber <br /> ISee3W(b)of P.L.94-579.Oat,21, 1976.43 USC 1732) <br /> I. Nat (firs/.middle initial.nrdinn) Address (include,zip code) Phare (include area code) <br /> 900 Stale SI. <br /> Salem OR 97301 503 3704003Willamette University <br /> 2. Allach map or sketch shooing public lands for which you arc appl)mg <br /> 3. Proposeddateis)of use: from 07/12/2018 to 09/15/2018 <br /> i Give legal basis for holding innael in lands in ❑ Resident ❑Partnership <br /> the Sue of Oreton ❑ Corporation ❑County <br /> (Check appropriate borat fight and explain.) <br /> Willamette University.is a private oat for profit educational Institution. 0 Local Government ❑Stale Gasemmem <br /> m Other <br /> 5. Am the lands non improved occupied or used? ❑YesmNo (!f5w."describe lmpoveent ad purposes,!dent uteri tad ocngmW) <br /> 6. D,)au need access lu lie land? m Yes 0 No (Describe meld or eambny access) <br /> The site Is adjacent to and within 30 fed of an existing areas road to the existing Thetford Lodge lease property <br /> 7o What do you propose to use the lands fate <br /> Septic dralnfeld evaluation for the edjocenl leased Thetford Lodge property <br /> b. What improvemmisand/or land development do you propose?/To complete applirvrion processing,engineering and construction dint lags <br /> nm)be required) <br /> None,for septic lest pit evaluation only. <br /> e What is the estimatedcapiml cost? d What isdc source of ware for thepmposed use? <br /> 5 None <br /> I CERTIFY Thain iinErmmtiionslam b)me in its application is ham comet and nano io debar arm)lmmsfdge and beleit <br /> �' J <br /> belief •o ghee it good fa . <br /> 'e `>(2, 07/122018 <br /> (Signal=of Applicant) (Dale) <br /> Title Ig USE.Section FOOLwillful!:m <br /> makes it a crime for any person knowingly mid willful! make to any department or agency of the United Slates <br /> aro fake.fictitious..or 1QWt ptmro <br /> oma car repWlimou wry nla wmareoidfm ejnv'vmGim <br /> (Continued on page 2) <br />