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� <br /> �CTIEC]K OFF i.IST FOR ISSUANCE O�' �E��TS <br /> FOR OFFICE USE ONLY� � . <br /> A.DD�tESS OR LEGAL: 1 3 S"b /��S fi i�U�'� � C��C(C <br /> PID: 0 ?- i 1 - � 3 - b0 <br /> 7�ESC�tIP'I'SON OF WORK: G� � ------------------ <br /> ---------- <br /> ------------------------- <br /> ZOYING REVIE�V BY: ^---_^______ DA'I'E APP�OVED: • D <br /> �UILDING R.EVZE�V BY: � . . DATE.APPROVED; � o-zZ-o-�. <br /> �k'EES TO BE CHARGEA• � Misc. Fees Calculated By: <br /> P���T Yes � No <br /> PLAN REVIEtiV � Yes �/ No SE�YER CONNECTION <br /> STATE SURCHARGE Yes �/ No _ tiVATE.RCONNECTION <br /> INVESTIGATION FEE Yes No _�/ PARK. FEE <br /> SAC Yes No ✓ SITEINSPECTTON <br /> Number of SAC�Units �p� z � �-r>•=�! OTHER (specify) <br /> -------------------------------- <br /> ----------------------------- � <br /> �p�t��IG CH�CK LXST Zoaing District; �. — � . <br /> ' Post Office; School District: � � <br /> Fire Depar[ment: <br /> Acres .3 Widch �o �0. 2 -= Depth J7 � <br /> Lot Area: Sq.ft. - <br /> Survey Submi[ted: Yes � No <br /> Date of 5urvey: ��y�G7 1'2.v fjr7�Q� <br /> Proposed Setbacics`. � QAF�- � : <br /> Fron[(Lake): �d�t Side: ��.s , <br /> � t�QS�-, . �. <br /> Rear (Street): �f'Side: � _ <br /> ��j3�P�� SrnirnlI�S; •'/-F tivatl2l�: <br /> � <br /> Suil�lin� Height: DeF, Hgt, Peat�Ho�• - <br /> Lot Coveca�e: �"'�•3���0 <br /> �(��y��y; �_ Counc�Approval Date: ' <br /> GradLn�: Scaff Approval Date: A� <br /> Septic: Staff Aporov�Dzte: � �Y� �S� <br /> � � Resolutioa Da:e: O� lG� 4/id�l£ <br /> 7oa�n� File: ��� Resolutioa: n — �4 <br /> Shoczland District: <br /> Avg. Se[bzc�:: Q k B!�F;Setback: I.o!Coverz�e: <br /> ��sting Proposed <br /> �q� � A <br /> H�ecovPr: G-7�' �. g o►r 28 33�p � 4 <br /> 7�-250' <br /> � <br /> Z�Q-���.;' <br /> ����-i CS^,!�' � <br /> y�`.-l�'2 �'yL".i2�. ,�?- ✓ �,"` �_._ 0: �v�--'- � - — vr� <br /> N�=C�O`;z� !. � <br /> �c��L-`�g,;-�ti �Ln h���e�' /5�v�-- ��� � C1/V (`/L. � �/�/��L� <br /> 1. J <br /> ����. J�( v _ I _ _--- <br />