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• <br /> • <br /> MARION COUNTY BUILDING INSPECTION DIVISION <br /> 5155 Silverten Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 <br /> Fax: (503)588-7948 <br /> • LAND USE COMPA.TIBILITY STATEMENT(LUCS) JJUN 15 2021• -=1) <br /> FOR ON-SITE SEWAGE SYSTEMS , <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> DATE: ts (14 121 <br /> MCBI File#: • <br /> SECTION 1—APPLICANT INFORMAITION <br /> ' 1. Property Address: 1.1°C \C(*.L. 5V Property ID#: <br /> . <br /> Sectian: .• Township: Range: Tax Lot#: , <br /> 2. Name of Applicant: Vitt. Caf..?ti.4-- Telephone#: 5-0 "2) -393-105? • <br /> , Mailing Address: RV IbOX- Q1k171 <br /> 3. Describe type of facility the on-site sewage system will serve(business;residence or other): <br /> ?:5Ingle Family Residence <br /> . CI Business. • <br /> • <br /> • <br /> LI Other: <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> : l New Installation Permit <br /> epair Permit ' <br /> CJ-Alteration.Permit for: 0 Replacement Dwelling 0 Bedroom(s)addition <br /> • 1:1 Other changes in land use involving potential sewage flow increase: <br /> • <br /> ) GAFORMS\SEMOApplication Packets\S-39 LIJCS.doc MC;S-39 icy:8/10,04/12 <br /> • <br />