71-T-12s For "~fice Use Only:
, Case No,
N FOR A i USE PERMIT
TO PARK A M 0 B IiL E HOME
(NEW AND ~)
(Following information is" to be typed or printed)
Name of Applicant: ~m%~, "--~~ ! I;1~ ;Yq ,~ ._~,,.~¥ ....
(MUst be owner & o~cupant of the Mobile H'ome~)
Address of Applicant ~ L~., [~e ~
Zailin~ address where mobile h~e will be located ~.
'Magisterial District_j)'~,,.<.,,,,,,~q ,, ,"~ Tax Map No. /1~
Subd. Name ............ Lot or P~rcel ~ 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 .....
~ '
(If app4icant-ts no't t'he ~wner'of the property in question,' ·
explain.)
If mobile home will remain unoccupied, explain
6. Time requested for mobile home to remain at site (use permit
g~anted for a maximum of two years only.) ~,
months / years'
?. Size and type of mobile home to be parked on the above noted
property. Make--~2~___Model /~"~ ~olor~ ~'~.~.~ Width
Length ~ /~ No. of Bedrooms ~,'- No. of Bathrooms
8, Source of water supply,
Method of sewage disposal ~ ~'?~. ~,~,~.,
' Information obtainable from the office of the County Assessor
(Room 213) ·
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).
Tax Map No. ~
Block No.
Owner ( ~-ff Occupant (
Lot or Parcel No.
Check One Only
I do object I do not object
( ) (
N~e (print) Owner ( ) Occupant ( )
Tax Map No. Block No. Lot or Parcel No.
Address:
Check One Only
I do object I do not object
( )
Signature:
Name (print) ~ ~.~ /j. ~ Owner (~' Occup~t ( )
Tax Map No. Block No. Lot or Parcel No.
Address :.
I do object
(
Check One Only
Signature:
Additional spaces on back of page.
I do not ob~tect
(2)
Tax Map No. Block No. Lot or Parcel No.
Address: ~ 7 ~/~g c~r- ~,~--~/--~'~--/~,, d>//~< ., ,
I do object
( )
Check One Only
I do(no~/~)bJ ect
Signature:
Name (print)
Tax Map No.
Block No.
Owner ( ) Occupant (
Lot or Parcel No.
Address:
I do object
( )
Check One Only
I do not object
(
Signature:
Name (print)
Tax Map No.
Address:
Block No.
Owner ( ) Occupant (
Lot or Parcel No.
I do object
( )
Signature:
Check One Only
! do not object
( )
***********************************************************************
Name (print) Owner ( ) Occupant ( )
Tax Map No. ., Block No. Lot or Parcel No.
Address:
I do object
(
Signat ute:
Check One Only
I do not object
( )
(3)
The Chesterfield County Health Department must make an inspection of
the proposed mobile home location, both before and after the mobile
home is installed. It is the applicant's responsibility to contact
the Health Department and make an appointment for this inspection
(telephone - 748-1S98). The inspection form must be attached to this
application.
The Applicant and/or his agent must be present at the Board hearing.
1/We hereby certify that all of the above statements and the statements
contained in any exhibits transmitted herewith are true. Further, that
all owners and occupants of adjacent property have signed Section No. 9
of thl~ application and have been notified of~the date and time of the
hearing.
ApPlicant's signatu~" -
Subscribed and sworn to before me this
My Commission expires,,
Not~
Date
SUBJECT: Luspection For Trailer Renewal Permit
For: County Planner
An inspection of the sewage disposal system and the environment of the above
trailer site was made by the undersigned, this date.
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 renewal of
permit.
Recommend denial of renewal for the following reasons
Other
Di s~ribution:
Original to AppLicant
Copy to Com~t~, Planner
CoPY Tm. File