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• <br /> • <br /> MARION COUNTY BUILDING INSPECTION DIVIS E C V E <br /> 5155 Silverton Rd NE <br /> 1111111 Salem OR 97305 MAY 11 2023 <br /> (503) 588-5147 <br /> • Fax: (503) 588-7948 MARION COUNTY <br /> BUILDING INSPECTION <br /> LAND USE COMPATIBILITY STATEMENT (LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: j— 2:7-23 MCBI File#: • <br /> SECTION 1—APPLICANT INFORMATION <br /> 1. Property Address: l 3 Ckuf?Ck St Property ID#: C 1T10 q PC0100 <br /> A.) hA D( ci73!0 • <br /> Section: Township: / Range: Tax Lot#: 1 1 d 0 <br /> 2. Name of Applicant: SJAv i A KokoN as . Telephone#: '1 15-7141 -4 K 7 <br /> Mailing Address: PC) (gip <br /> A.N irk a + 0k °c73 O • <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> ❑Single Family Residence <br /> ❑Business - <br /> C Other: 5kp <br /> • <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> C New Installation Permit <br /> ❑Repair Permit <br /> ❑Alteration Permit for: ❑Replacement Dwelling ❑Bedroom(s)addition <br /> ❑Other changes in land use involving potential sewage flow increase: <br /> G:\FORMS\SEPTIC\S-39 LUCS.DOCX Rev:8/10,04/12,03/18 "w <br />