HomeMy WebLinkAboutPermit 633B12
n 0'60 vV,\)V LANe
--4'~o~tk~~~ A ~~~A~~~~~~:'U~~~I~~;~~'T
Owner, Name, j1-~~h.6~:f~j<<-rT" h..h___,___,h ___'.0 .0 .0.0 .0 '.0 . ... .' .
Address, 'h.___.~::l h'h~t~..:;t~/.. '.-:2x,../:-." h .0' h h .. "h hh'n_._n_n.
Applicant, (If other than owner) Nome, h___,,4~\..t:~""~:~"h'___'h'hhh'h"'h___h"h'h""'h.._.n '.h.''h'h'.hhm..'hh..'h_.'.._.'..h..h.
'h.,~.:~'~::"':;;:..;:;:'..;::,,~;_;};;;;;?'m~:.~~,~m 1
PERMITS APPLIED FOR, (Check those applicable) BUILDING (Estimated Cost) h..h'.'.m.h.h.:h"d.___t!::~fJ.h______h___'n'.hn.n'..m
IND. SEWAGE DISPOSAL SYSTEM, h,..,',.h.~"hh..n.'...'n".m'-....,...-,
KIND OF CONSTRUCTION, ,~~,li..~l,.~,,:::::;;,'~~~~~~~:::::::::::::::::::::::::::::::::::::::::::::::::",'.'.=~~::::':::':::.:~~~::~::,~~,~_
::~~:~~~::;':,:=:,m~::::~~~.~'~";..~"2i'~~:f~m~tu>
Township, ,h.l,'h7.___'hhh'.", Section, ..Lt.'h' Range'"''h'h''' or lot, --LL'h' Block, ,h"h'h,. SubdivIsion, ,'7!:L~.4., h"h"
Zoning District, Agricultural, "h..___h""'___'h" Residential, "'h~hh Commercia" "h'___h"h"".,.. Industrial, "h___'h,___"dh.'
A Plot Plan showing the following must accompany this application,
1. North Direction 5. Street name or road number
2. location of Proposed structure on lot 6. Locations of existing structures
3. Dimensions of frant and side set. back 7. locatian and size af Septic Tank and Orainfield
4. Dimension of structure (s) 8. location of well,Distance from Septic Tank and Drainfield
Applicant hereby agrees that, in case above permit is granted, that all work shall be done and all materials which shall
~~du~a~~~a~pc:,:~~e ~~~r:~o~ ~~~;.:n~~ ,.0,' os. ~e,re~it~ su. mitte.d..,a'~'~h,~,i.~~.,~he ~r~Z,:t,73hiP
11-< App" ant', Slgnolu,. FDaI'
'~~h- B.-: !.;<...___
PERMIT NUMBER
Phone,'fC(?-:..?.J:.'i)
~ . TOWNSHIP USE 0 LY
Recommend Approval, 'h.h.'hh,",.'hh..",h,..h'."" Recommend Disapproval, h'h'h'h"""h""'h'hh"'h" Approval recommended
su biect to the fo Ilawi ng cond it ions , h,"hh'__________'___h"'hh,'_""'__'___'h'h""""h. 'h,m"hh"""hh"h.' h.h,".,'..",..h'h..h'hhh___.h,h'h.__.
..",", 00, ,;..,~~", ..mm.m...mm~~~::'-:;'71:....mmm..m ....m...m.f;:.~7m
SIGNATURE OF TOWN CLERK. (Or representative) "'h..Ih' h h.h.___m.'..':{.,':.h."..'hh....,'h'..,.h'h.___h,.h DATE. "h.ml'h'h:'5.
COU TV USE ONLY
Approved, "'~' Denied, ___'h'___""""h By Planning and Zoning Coordinator subiect to existing regulations and the
following cond itions, ',...,h,"h.hh,.h___"",h.,h,h.h..'h'h.'h.h'h,_h'. .h__h'h,___.hhh'h"h""___""'''''''___'h'','h''h'h.h'___'h'___'h.h"'h_',".._
~;~~~;~~~:h,.::~',2i~I~_~::::::::::::::::::::::::::::::::::::::::::::,::::::::---~~;~:':::,::,::,,::,::,::,:::::.:':
~7,Hi
I 2-, s- C
~- ~c)
WEll ,....h....'.,..h'h...,. "
TOTAL FEE "..0.'.0, $_/J f: i2.JL J RECEIPT NUMBER, ''''h3.J:ZO'''h'''''h''''''
Type, ~~3.'""'::""'h-"'~'~h""'h' Dale, .,~,~t:'-" h'h~:.-:.,.t-:,-?-J....
FEES PAID,
BUILDING PERMIT ",,,, ~
IND. SEWAGE DIS. 'h'
INSPECTIONS,
fORM NO. 1
{Rev. 11-14-691