75SR017.4.
BOARD OF ..,JPERVISORS
CHESTE,<FIEL. COUNTY
CHESTERFIELD- VA.
~or Of~'~Ce Use Only:
No.
Zoning
E ~"
(~ollowin8 information i6% e or
(~us'~ b'~- OCher"&" bcEupaht of' the MOb-i"lE Mo~e)
Address of &pplic~ ~,, _~,,, ~, ~'~ ~ Telephone~
Mailing address where mobile ho~ will be located ........
.Magisterial Distric~/~/~- Tax Map
S~d. Name ,__ , , ,, Lot or P~cel : Blk. ,,. ,,Sec.
A map of this property must be attached to this application,
This map must be to scale.
Name of~/os~o~ner of prope~ty~.//~~/~,~/fen which mobile home will be parked ,"
-'('If th& Epplican~ i's fief ~de 'o~r 6f the pro, ertl' in-'q~s~i0n, '
explain. ) ,,, ,
5. If mobile home will remain unoccupied, explain
6. Time requested for mobile home to remain at site (use permit
granted for a maximum of two years only. ) m'~h~'hs ..L~ _. years
Size and type of mobile home to be parked on the above noted
property. Make~.~ f,p~g ! Model Fq,
Length _:.¢~ .... No. of Bedrooms
Source of water supply ~//
Method of sewage disposal %6D~..d
No. of Bathrooms
Information obtainable from the office of the County Assessor.
( Room 2lB )
' 9. Information, addresses, and signatures of all property owners,occupants
who are adjacent to the parCel on which the mobile home be located must
be provided in the spaces below,
We., the undersigned owners and occupants of the adjacent
property to the property on which a mobile home is proposed to
be located, hereby certify that we do or do not object to the
granting, of a Use Permit to park a mobile home on the property
described in this petition.
Information available from the office of the County Assessor (Room 213).
Owner ( ) Occupant
Lot or Parcel No. ?
Check One Only
I do object I do not object
( ) (kg)
Signature: Iff/" ~/~{2~ .. _(~q.~ ~v/~O-'~'~7_... ...../-
Name (print) ~/-/q ~X-[~ ~rI~ Owner ( ) OccuPant ( )
ax ap,,o.
~ec~ ,One OnlM ~~
I do object I do not object
******************************************************************
N~me (print) ~~ ~ ~'~~r~ Owne~ ~ ~ Ooou~t
· ~x ~a~ ~o. r~--~ ~ ~oo~ ~o.~ ~o~ o~ ~a~oe~
I do
(
Signature:
Cbe~ck One
object / /~./'" I do not object
Additional spaces on back of page.
(2)
Address:
) Occupant (
Lot or Parcel No. ~/
Check One Onl.y
I do n~/~bJect
(
I do object
( )
Signature: ,,~. ~~, ~
Name (print ~/~/f~,F/.-'J o,, ~ O 0 ~/' Owner (
~ ~ ~o./?//~ ~oo~ ~o.
Address:
Cheek One Onl,y,
I do object I do not object
( ) ( )
Signature:
) Occupant ( )
Lot or Parcel No.
~._ ~/~~ .....
Owner ( ) Occupant ( )
Name (print) ~
Tax Map No. Block No. Lot or Parcel No.
Address:
Check One On![
I do object I do not Object
( ) ( )
Signature:
***********************************************************************
Name (print) Owner ( ) Occupant ( )
Tax Map No. Block No. . Lot or Parcel No.
Address:
I do object
( )
Signature
Check One 0nly
I do not object
(
(3)
10.
ll.
THE A~PLICANT HEREWITH DEPOSITS THE SUM 'OF FORTY-FIVE DOLLARS
($45.00) TO BE ATTACHED TO THIS APPLICATION TO ASSIST IN
DEFRAYING THE COST OF PROCESSING THE SAME.
A) Check or money order must be made payable.
B)
to: Treasurer, County of Chesterfield
Application fee ($45.00) is not refundable.
The Chesterfield County Health DeDartment must make an inspection
of the proposed or existin~ mobile home location site (both new &
renewal). It is the applicant's responsibility to contact the
Health Department and make an appointment for this inspection
(telephone ~- 748-1398). The inspection form must be attached to
this application.
12. APPLICATION WILL NOT BE ACCEPTED FOR PROCESSING UNLESS OR UNTIL:
A) All questions have been answered
B) Location map or plat is attached
C) Health Department inspection form attached
D) Application is signed and notarized.
THE APPLICANT AND/OR HIS AGENT MUST BE PRESENT AT THE BOARD HEARING.
I/We hereby certify that all of the above statements and the statements
contained in any exhibits transmitted herewith are true.
Apolicant's Signature
Subscribed and sworn to before me this ~. day of/~.~~
My Commission expires //-/~(~,--~ ~ ~/
(NOtarY pUblic)
(Page 4)
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