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REC'U JUN 15 2021 <br /> MARION COUNTY BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 D ( Q <br /> (503) 588-5147 <br /> Fax: (503) 588-7948II- JUN 16 2021 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> LAND USE COMPATIBILITY STATEMENT (LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: / 1 I b2,\ • MCBI File#: <br /> SECTION 1—APPLICANT INFORMATION <br /> 1. Property Address: qS U S� Property lD#: <br /> Section: Q1 0 L.Township: loS Range: S Tax Lot#: l . <br /> 2. Name of Applicant: S-OrYloolv bm J-4 \ Telephone#: qTi 61 - �2j0 <br /> Mailing Address: • 41 <br /> g523 St-u V` aK i01 l/1. <br /> • <br /> °clM q q <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 /> • <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> ❑New Installation Permit <br /> Rpe air Permit <br /> ❑Alteration Permit for: ❑Replacement Dwelling ❑Bedroom(s)addition <br /> ❑Other changes in land use involving potential sewage flow increase: <br /> • <br /> G:\FORMS\SEPTIC\S-39 LUCS.DOCX Rev:8/10,04/12,03/18 <br />