71-T-11S .~ / ~or Office t '0nly.
1.
of a ' .,~.~, /.-/2c_
(A) Mailing address where trailer will be located
e
4
(D) Sec. (~) Sl.~. (m Lo~ or pa~.~--/
Name of owner of trailer _/~OOe ~ -~0,,¢ ,., ~ .. ~~%~ ~~%/
N~e of owner of PropePty on which tr~e~ will be parked
Name of person who .will occupy the trailer_= ~~, ,, ~,.. ,
~~f~,~a~, ~. If trailer will remain ~oec~pied, ..
7. Time requested for trailer to remain at site (use permit granted
for a maximum Of two years only). O' z
' m~nth~' "/" years
8. Size and type of trailer ko be pa~ked on the above noted property.
· /
Make Mode 1 _Color t..,, .Width j~Length _
No, of Bedrooms ,. No. of Bathrooms /
Source of Water COUNTYL
Method of SewaEe Disposal S EpTI..C .. TANK .....
9. A plat (map) of this propemty must be attached to this application
This-plat must be to scale. ·
Information obtainable from the office of the County Assessor.
Information, addresses, and signatures of ali property owners and
occupants who are adjacent to the parcel on ~ich the trailer will
be located must be orovided in the spaces be.'ow.
We the unders1.qned owners and OCCL~ants of the
adjacent property to the pro.hetty on which ; trailer is ~ro-
posed to be located, hereby certify that we do or do not ob-
ject to the grantina of a Use Per~it to par( a trailer on the
property described ~n this petition.
Informa~ion available f~om the office of ~he C un~y Assessor.
N~e {print) ~O ~, ~J~~ Ow er ~. ~' Occuo~ ( )
T~ Map and Sec. No. Block No. L(t or Parcel No. ~
_~ck One Onl~
I ~0~'ct ~ ' ' I do no~ect
Signature: ~y~~~ (
N~e (prin~)~,)~,~ ~, ~~e~ 0w~er ( ) Occupant
Tax Map and Sec. No. ~Block No. ~ Lot or Parcel No.
~heck One Onl~
I d~~'ot -~ ' - I do no~bJect
Owner ( ) Occupant (
Lot or Parcel
Name (Print)~0~. W' /~,~ e.~
Tax Map and Sec, No. ~ Block No. ---___
Address: .~~ I]~'. /~ ~.
., ~eck One Only
. .I d~~ct ' ~-' .~
I
do not/)obJeet
( .
Additional speces on back of pare.
(2)
Tax Map and Sec. No. ~-://~ Block
Address: ,~,~ ~ ~/~ ~
I do object
(
Signature: .... ~ ,,, y
Check One Only
Owner
Lot or Parcel No.
I do n~'obJect
(
--Tax Map and Sec. No.x Block Lot or Pa. cel No.
~ ~heck One Onl.v
~ I do object ' ' I do not ~bJect
Signature:~ ~ .~t~ .~~, .
Tax Map and Sec. N~'-/~ Block Lot or Parcel No. ,,, ~ :/
Check One Only n~ct~e
I do object I do "
( )
., .~ ', t/.~ · . .
Name (print) / ~.-.~.~. Owner ( ) Occupant ( )
Tax Map Se~ No. ~>'/~,... Block Lot or Parcel. No. ~--/
Check One Only
I do object I do not object
( ) ( )
Signature:
(3)
The Chesterfield County Health Department must make an inspection of
the proposed trailer location, both before and after the trailer is
installed. It is the applicant's resoonsibility to contact the
Health Department and make an appointment for this inspection (tele-
phone - 748-1~98). 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~_.o~ners ~..09cuPants of adjacent p~ooerty ha~e signed Section
No. 7 of this application and have been notified of the date and time
of the hearing.
Aoplicant's S~ature
Subscribed and sworn to before me this ~O'-day of
My Commission expires ~
Notary pU~li c
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