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71-T-13sA P E'-~~ 0 N For ~fice Use Only: Case No. Zoning ~- ~ FOR A USE PERMIT TO PARK A MOBILE HOME (NEW AND RENEWAL) (Following information is to be typed or printed) Name of Applicant:~D ~ )~,/lf3. (.~'~ .~ ~f'/ ~ (Mus~ be owner & 0cCuPa~t bi-~h~ Mobile-Home) Address of Applicant_ /~~ x~: ~.~I~_ _~t~ Telephone~'~'~7~ Mailing address where __mobile home will be located #Magisterial ~istrict /~//~, Tax Map N..O. /? )~ 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°the app li.%~ explain. ) -- if mobile home will rem~l~ ~o~~d, e~ain 6. Time requested for mobile home to remain at site (use~~pe?mit~(x granted for a maximum of two years only.)~ 6~ ~m°nthS / year§ ?. Size and type of mobile home to be parked on the above noted property. Mak~Mode 1~.-~Co lor~Wldt h /~~ Length~No. of Bedrooms ~ No. of Bathrooms / ,~). 8. Source of water supply... ~ Information obtainable from the office of the County Assessor (Room 213) ' Information, addresses, and signatures 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 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). Name (prtnt)~/L~~//. f~~Owner ( ) Occupant ( ) Tax Map No. /~ ~ ~:~_ Block No.~_~ Lot or Parcel No. ~ Address: ~f~ ~~ ~ Check One Only I do object I do not object ( ) ( Signature: Name (print) /~~~~ ~,~~ ~ Owner (,~% Occupant Check One Only I do object I do not object (~.' -) ( Signature: ~~_~/~ Name No. Pa oe Address: /~/~. Check One Only I do object ( ) Signature: Additional~ sp2ces on b~k I do not object of page. (2) Tax Map No. //J'~-~/_-~ Block No. ~/'~ Lot or Parcel No.~ ~c~ Check One Onl~ I do object I do not ob.J,~ect ( ) ( ~ S ignat~e: ~~~ ~., ~~~ ~ ~ Name Tax Map No.''~~'//~/~No. C Lot or Parcel No. /V~ ..... '" '" ~%Jeet I ~ object Si~ature: Address: ~-/ ~~~ 5~ Check One Onl~ I do object I do not ~Ject Signature: ~'~. , '~ F~~ Name (print) , ~,- ~~Owner (~) Occupant ( ) Tax Map No. ~ ~~>~ Block ~0.~ ~ Bog o~ P~eel ~o. ~ ~,, ~ d ~ Check One I d~-o~ct ,,, Qnly I do (n~TbJ ccc 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 - 748-1398). The inspection form must be attached to this application. 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. Further, that all owners and occupants of adjacent property have signed Section No. 9 of this application and have been notified of the date and time of the hearing. AppLiCant ,~' Signa~ur-e-~--~-. Subscribed and sworn to before me this /~'.~ day of ~.~ 197_/. My Commission expires NOSarY PUblic -4- ...... ~ ~'~. ~ HEALTH DEPA~Ti,'~NT CHESTEP~IELD ~ VI~:GINIA ~ ' ,' ~ ,~ ~s~ for Lot ~vatuation Phone ~ M~ ~g.,~ , ' ~.~n e r Addr~s s :xact Location , , -- _ ~_ of Promises., ~'~~ ~ /~ ~ "~~~~ Lot Block Secti'on s~re~t s ~'di'vYs ion Applicant ~~sires to have a lot opinion that is s~oject to ~valuation prior to issue%ce of Building P~it. __/~ I~ applying for Building P~rmit ~'' Tvr~e of Construction ~ rwelling /~ Other /7 House ~lan not final __ to. ;~asher /~ Garbage Disposal ~ ic ~'~ater./7 Ind. Well' or potential bedrooms~Estimat,ad water cons=ptio~~pd. Actual /lecomm:~ndations: Basad on present standards it is our opinion that Soil for ?~tic tank ~d drainfield installation. ~'h'is is not a permit' t© ins'tall a Posted Grid .....