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4 , <br /> B551511DSilVeRSTrtOt <br /> r' ' MARION COUNTY5i <br /> Salem OR 97305 <br /> INRdSnPECTE ION DIVISION <br /> (503) 588-5147 ' <br /> i ......2" !•,:t <br /> Fax: (503)588-7948 <br /> _ • <br /> LAND USE COMPATIBILITY STATEMENT(LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: 1- 2.1- Zrz... MCBI File II: <br /> stcnoN 31-AF'PLICANT INFORMATION <br /> 1. Property Address: 0 49 r7 H _ Property IG#: <br /> A IAN,6 e•-..,0 ete 17 oat.. • <br /> Section: Township: Range: Tax Lot#: <br /> 2. Name of Applicant VektextiOar toifirife%Way ,e-ArOAttell Telephone 4: 50 (07g-Z.773. <br /> Mailing Address: Po ''' r;,x 111._:_5" • <br /> tetkkir cort.1_ oil- (t2sto7--- <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> U Single Family Residence <br /> CI Business <br /> IA Other: ___ x1;.44,14, L_____ , <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> C:1 Nevv Installation Permit <br /> CI Repair Permit <br /> 0 Alteration Permit for: E3 Replacement Dwelling CI Bedroom(s)addition <br /> Other changes in land use involving potential sewage flow increase: 571ket'eas: 1--‘ <br /> . no pky ;c,ai. 0_,kowlga -vo Ei- wto...u... +0 A.deliVien" 6 friacha <br /> 1&L P roP•erfy et. 64A:it-of i 145, <br /> OAFORMSNSEPTICkS-39 LUCS.DOOX Rev:8/10,04/12,03115 <br />