75SR035For Of ce Use Only:
Zoning. ~.~-~ ......
APPLICATION FOR A USE
PERMIT
10 P A R K A M,~L E H 0 M E
(NEW AND (~w~w~w~f.1
owing1~~~~~~inf°rmati°n i~typed or printed)
( Must "' "6' ~ owner & oc~u~t bf ~h~ M°~'le'~o~e)
3. Mailing address where mobile hp~ will be located,~f~¢~~
Subd. Name
Lot or Parcel Blk.
.... Sec
A map of this property must be attached to this application.
This map must be to scale.
Name of owner of property on which mobile home will be parked_. ~
explain. )
5. If mobile home will remain unoccupied, explain.
Time requested for mobile home to remain at site (use permit
granted for a maximum of two years only.) ' m6hth's ..... /- y~-s~ar
Size and type of mobile home to be parked on the above noted
property. Make_ _:~. Model
Length ~b No. of Bedrooms
Color W',-dth
No. of Bathrooms
Source of water supply r~f~-~'_~ ,,/'F"Cr"---~,, _
Method of sewage disposal ~,6~..~,~ ~
information obtainable from the office of the County Assessor.
( Room 213 )
9. Information, addresses, and siKnatures of ali 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
gr~nting of a Use Permit to park a mobile home on the property
described in this petition.
· Information available:m the office of the County Assessor (Room 213).
'"Nm
me (print) /. . Owner ( ) Occupant ( )
Tax'Map No..,,>%~:-- ,~ ~h Block No....Lot or Parcel No.~~y
Address: .~1~ ~./~/. , ~~ ~ ". ' _ ..........
Check One Only
I do object I do(not~obJect~/)
Signature: ~,. ~ '
Name (print) j~-/~,~/2C// ?~/. L~.f~~o~er ( ) occup~t ( )
Tax Map No. ~ 7 ~ ~ Block No, ~ Lot or Parcel No.
Check One Onl~
I do object I do not object
( ~.) ' . ( )
Name (print) /~/~/n// /~ ~j'~ (J/L. Owner ( ) Occupant
Tax MaD No.._A:-~" ~/~/ Block No. /~jA Lot or Parcel No. /]
I do object
( )
Check One O~ly
I do not object
( )
Si gnat ute:
Additional spaces on back of page.
Tax Map ilo. ~q -~ ~)
Address' ?~'' ~' ' '
· / ~ ?, .. _.~.~' ~)q.. ' ~'%-Z-'~L~.. '
~heck One Only
I do object
)
f4L:.~,. ~. ?. ~' ~/', /i ~ O~rner ( ) Occupant (
· ,, .. ~,.~ .......
Block No. ~-- Lot o~'~
I do not object
( ,~:~ )
Signature'
Name (print) Owner ( ) Occupant ( )
Tax Map No. Block No. Lot or Parcel No.
Address:
Check One Only,
I do object I do not object
Signature:
Tax Map No.
Address:
Check One Only
I do nO~) -Ject
(
I do object
( ) / ;
Name (print) O~ner ( ) Occupant
Tax Map No.
Block No.
Lot or Parcel No.
Address:
I do object
( )
Check One Only
I do not object
( )
Signature:
(3)
10.
ll.
12.
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.
to: Treasurer, County of Chesterfield
B) Application fee ($45.00) is not refundable.
The Chesterfield County Health Department must make an inspection
of the proposed or existln~ 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 .- 7~8-1~8,). The inspection form must be attached to
this application.
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 attsched
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.
· ~,Oplicant "s Signature
Subscribed and sworn to before me this., l._~ ..day of ~Q~.
la
i,--/ /
( Not g~Y pUblic)
(Page 4)
Date
SUBJECT: Inspection For Trailer Renewal Permit
For: Co~~
An inspection of the sewage disposal system and the environment of the above
trailer site was made by the undersigned, this date.
The Following report is submitted:
Health Department finds no environmental health hazard
An environmental health hazard does exist, as described below, therefore,
the Health Department recommends corrective action prior to rene~ of
permit.
~_/ Recommend denial of renewal for the following reasons
Other
2emarks
Distribution:
Original to Applicant
Copy to County Planner
Copy T~_File