75S036BOARD O[ 3UPERVISORS
CHESTERFIELD COUNTY,
CHESTERFIELD, VA.
For O£'~e Use Only:
Case 1~)o. i .... '11.~ .....
Zoning ~'3
APPLICATION FOR
A USE PERMIT
¢o MOBILe HOM .
N~,W. AND RENEWAL)
,,~~(Following information is to be typed or printed)
.~, _~,,.~.~ ~,~:~' ( u'M '~b be ow~er & ~c~¢ahtp of th'e Mobile' Ho~e')
~ ' Tee hone I-
'.~Mailing address where mobile ho~ will be located .........
............................
'Magisterial Dlst.ict ...... ~~~A :~-Tax Map Ne. .........~/ ')~
Name ,, Lot or Parcel/~'~ Blk. .Sec.
A ma~ 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 th~'" applicant is not the oWh~r Of the pr'0pert'y"tn~ques~lon' ' ~ '"
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.)
~ m0nths '~/~ years
Size and type of mobile home to be parked on the above noted
- LW"6'" Width
property. Make--Model Co~or vJ~,-,r~ ,_ ,, ~
Length ..,4~/ No. of Bedrooms ~_~ No. of Bathrooms _,_. I
I
Source of water supply .......... ."--'~c~LtO~ ....
Method of sewage disposal ~.,~'"F"~, C.... ~'¢",,~ ~
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 °ccupants 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 (print)~~y£~Kzy~/~.~f-~,.~wner ( )/~Occupant ( )
' , Check 'One O~y
i .,
Si~ature: .... , _ ,
~ (P i~t) ~- ~.. ~~Z~ Owner ( ) Occupant ( )
Tax Map No. ~~ ~ ~F
. ~o~ ~o. ~o~ o~ ~~ ~o.--_./~ __
Check One Only
I do object I do n~ect
( )
Signature: ~~ fr~
N~, (prin .t~w ~_~/~ ~Z~ Owner ( ) Occup~t ( )
Tax Map No~/~..~ Block No. Lot or Parcel No....../~
Address: .... ~ ~ ~~~~/~ /~. > fl ~ '~
/~ Onl~
Check One
I do object I do no~ object
( ) ( )
Signature:
Additional spaces on back of page.
(2)
I ~o object ..~ ~ I ~o not ~.obJect
Signature: '~,. .......... ~ ........... ~,,,,: .................... ,'t' ...: .... ...... ~ ......
Name (print)
Tax Map No.
Address:
Block No.
Owner ( ) Occupant ( )
Lot or Parcel No.
I do object
(
Check One Onl.y,
I do not object
(
Signature:
Name (print)
Tax Map No.
Block No.
Owner ( ) Occupant (
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)
10.
11.
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.
B)
to: Treasurer, County of Chesterfield
Application fee ($45.00) is not refundable.
The Chesterfield County Health Deoartment must make an inspection
of the proposed or existing 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 ~- 748-1398). The inspection form must be attached to
this application.
12, APPLICATION WILL NOT BE ACCEPTED ~OR PROCESSING UNLESS OR UNTIL:
A) All questions have been answered
B) Location map or plat is attached
C) Health Department inspection form attached
D) Application is signed and notarized.
THE APPLICANT AND/OR HIS AGENT MUST RE 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.
Ap mOlicant ' S~ignature
SUbscribed and sworn to before me this ~? day of
i-~L~?~m~!ssion expires ~/>~/~
(Notary Public')
(Page 4)
SUBJECT' Inspection. for Trailer Rene~al permit
FOR: County Planner
~cation of '~railer ~3~qO
6,~,~ Phone
;n 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:
/_-7 Health Department finds no environmental health hazard
/7
An environmental health hazard does exist, as described bel~w,
therefore, the Health Department recommends corrective action
prior to renewal of permit.
/__~ Fecommend denial of renewal for the following reasons
~ Other
Remarks f'£.~_/~,.J',~ ~' . /q.,./,?.~_.:_ c...~:f.~/'T,t~,~: ,;- r~ ~,,.O ,'£~I/
Distribution:
Original to Applicant
Copy to County Planner
Copy to File
- ~ Sanit ari-an
Phone ~ 748-1 ~9~-~
Address =/o ~w-~,.,7'~,~c- ~ ..G£¢ ~ ~ /~o~
~ Phone
~cation of Trailer ~ ~t~,J ~fl F'- ~ ~)
~ ins~ion of ~e sewage dis~sal sys=em ~d ~e envi~t of
~ove trailer site was ~de by the ~dersi~ed, ~is date.
$53JECT: Inspection. for Tr~ Renewal Permit
FOR: County P1 annex
The following repor~ is submitted:
/__7 Heal~z Department finds no environmental' health hazard
/7 ~ environmental health hazard does exist, as described helps,
-- ~xerefore, the Health Department recommends corrective action .
prior to renewal of permit.
/7 Recommend denial of renewal for~e following reasons
Other
Distribution:
Original to Applicant
.Copy to County Planner
Copy to File
' '- Sanitarfan
Phone: 748-1 393"