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~n~ APPLICATION FOR BUILDING PERMIT . nilffl~~8"I9-:.~(j~-:jZ
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PERMITS APPLIED FOR, (Check those applicable) BUILDING (Estimated Cost) nm~ntl~~~...;Y;jmmnnm.--~m
IND, SEWAGE DISPOSA~, m~n___~~ :,.jn~4::!.___~.m___nnn______
KIND OF CONSTRUCTION, m.m.d%d:___Z'~j~;':i~::::_,f.;;~:~~~~.:::::::::~~::.~::::::::::~:::~:::::::::::::::~:::.
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Number of .Bedrooms, n---------T-7z~---m:~7.---7m~/?n//yneral ~tract~r' ';?"';9WJL4i1.--:~t!!..,fLL.~------
Legal Descnr>;,n, of ZO.;:rty, ~L.-~~..L~[__~..t!nL~nc?!~/.O-?~~~B-~~oo~-C:n~m';lJ&/!~~.~nmm~n~~nn~.~m.~.
Townshi~L'J'r-n~~~_~__I;,,~ Section, oo/~~~~ Range, oomn~___~ or Lot, ~Ll2m IlGck, ~~~~__~~____ Subdivision, nn~~.~~n___nnn~mmm
Zoning District, {gricultural, n___mm~___nm~m Residential, m__~~____m~__nn. Commercial, moomm~mm~m Industriol, ____.m.___m~_~m
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 front and side set.back 7. Locatian and size of Septic Tank and Drainfield
4, Dimension of structure is} B. Location of well~Distance fram Septic Tank and Drainfield
Applicant hereby agrees that, in case abave ermit is granted, that all work shall be done and all matenals which shall
be used shall comply with the plans SZifiCO' s ~ submitted and with the ordin~nce~f S 'd Township
and County applicable thereto. ,,~/' . /2 v/ --f
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p Icant s Signature Date
~ TOWNSHIP USE ONLY . .
Recommend Approval, n.~~~~n___~~~moo___nm___~___~___~Rec mfj~,,::oval' m____m~___nn___m~______~~~~~~ zr::;lrilJme<1ded
subject to the following COnditio~n~~::m:.&~~~~n moo m_ --;7.jf-~-?-a~:;;:mn~.~~~mm~mmoom~~~~ ~ ;lJ}ja~ .
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Approved, ~~__~.~___ Denied, ~m___~~nn___nn By Planning and Zoning Coordinator subject to existing regulations and the
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FEES PAID,
lNSPECTIONS,
FORM NO, I
IRe.... 11-14.69)
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BUILDING PERMIT ....00 $;~ 7. fJ 0
IND. SEWAGE DIS. n.~ 2?-an
WELL muuU~~hn~~~~___~m ~ ~ on
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