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72-T-1SFor C~ice Use Only: . Zoning ~ -Z-- ,,, A USE TO PARK A MOBILE HOME (NE_~W AND RENEWAL) (Following information Is. to be typed or printed) PERMIT Name of Applicant: ~m~,=_~ L,'~1¢1% ~ NCtqct (Must be owner-~ OcCupant of the MObile Home) '" Address of Applicant ~¢~/ ~~./ ~/¢~ Telephone~F Mailing address where mobil8 h~me will be lacated "Magisterial District/¢~~ Tax Map NO._.~ , ~ '~ --:.~ Subd. ~Ame~t~.~~,, Lot or Pa~e~¢,,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__ ,,, 4. ,fl... ,, ,..1.l (If th~ appltc~$5'is'~n_9~ 'th~ owne~ 'o'f the property in q'ues~i~n, 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.) months / years 7. Size and type of mobile home to be parked on the above noted property. Make~odel & 2, Color Width Length ~-/,, , No. of Bedrooms Source of water supply No. of Bathrooms / Method of sewage dlsposal__~_~~ Infoz~nation obtainable from the office of the County Assessor. (Room 213) 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 2lB). Name (print)~_~~... ~~.~~ ..... Owner ( )/0ccupant ( ) Tax Map No. Block No. Lot or Parcel No.. ~'~ Check One One7 I do(object) I do(notf~hJeetf,.~) Name (prlnt),~u~c,_-~-~. %~)~e~[~%4 Owner ( Occupant ( ) Check One Only I do obJsct I do not oDJect ( ) ( Signature: P~_.~..:z. ~~ ~'~ Name (print)~c,~,.~ ~. ~'~r~ ........... Owner .~P~t ( Tax Map No. Block No. _ ~~~ Parcel Ch~~ Only I ~o obJec~ ~ I ~o(no~ect~) - Sl~ature Additional spaces on back of page. (2) Tax Map No. ~ [ OR, Block No. /~ ~Lot or Parcel No.~, Check One Only not ~' I do object I do ( ) Name (print Tax Map No. Owner ( ) Occupant Block No. Lot or Parcel No. Address: I do object ( ) Check One OnlM I do not object ( ) Signature: Name (print) Tax Map No. Owner ( ) Occupant ( ) Block No. Lot or Parcel No. Address: Check One Only 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 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 - 748-1398). 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. ~- - Appli'c~nt '~s- ~ignaSur~e Subscribed and sworn to before me this,,/5, day of ~~,. 19~. My Commission expires Phone~ ~,~n e. r ]~xact Location of Premises Lot S"ubdi'viS ion Applicant Block S'sction Street /_~Desires to have a lot opinion that is s~oj~c to re-~ t evaluation prior 'to issuance of 3uildinq Parmit. /7 IS applying for Buildin~ Permit Type ~f Constr.uction /~r,/ Dwelling /___~ Other /7 House plan not final ~/--/ Auto. ~asher /-7 Garbage Disposal /~7 Public ~'~?ater./7 Indo ~qell ~..ctual or potential bedrooms ~'~stimated water consuraption~g~d. )?;ecommendations~ Based on present standards it is our opinion that {~ot has ~ /// FAVOP3~SL~ /7 QUESTIOL]LBLE /7 NOT SUITED ~il for septic tank ~d drainfield instal~tion. ~]]"is"is not a permit to i~s't"al'l a Sadi~arian 5at-a ....... Posted Grid lib IIA ~'510 9903 ll-I Reyme General Blvd. HOusE HGT$,. PB. 4Pg.184 Iog~ \ 9 '~424 2418 2400 Rd. ~ Z R~ pooJ 9s~o~ 2 2~ 18 19 17 21-1 82-14 ~ CD DA DISTRICT SECTION 82-13 ,f.