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MARION COUNTY BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 <br /> Fax: (503) 588-7948 <br /> EXPIRED <br /> LAND USE COMPATIBILITY STATEMENT (LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: I 0- - 2 v MCBI File#:2° —QG 3-92? ' AT`' <br /> SECTION 1-APPLICANT INFORMATION <br /> 1. Property Address: ass..s L t,•/oov frt... Property ID#: <br /> lea E rL <br /> Section: Township: Range: Tax Lot#: <br /> 2. Name of Applicant: 5cerc. r,�/ &nj _ Telephone#: S31-5;Q-5 A)�4 <br /> Mailing Address: Q 6o' <br /> (NR,� 1 o2. 'i7.?(OO <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 /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> ❑ 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\Application Packets\S-39 LUCS.doc MC:S-39 rev: 8/10,04/12 <br />