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' �HECK, OFF i�IST FOR ISSUANCE O�' PER.�.�ITS <br /> FOR �FFICE USE ONLY �3�� ��� � <br /> ' AAARESS OR LEuAL: lo(�C� N�% <br /> PID: <br /> �� �F���' (�, r F�u=, s v4 � <br /> J}ESCRIFTT . `Yvt.�.�Ok.Z 0 _ <br /> _---------- _—__ <br /> ---�-_--__--.-------------- <br /> ZOV�G REVIE�4V BY: N DATE APP�OVED: <br /> SUJZDLI�IG REVIE�V BY: � . DATE APPROVED: f- Zz-�-7 <br /> k'EES TO BE C�-IA�RGED: ! Misc. Fezs Calculated By: <br /> PERMIT Xes ,� No <br /> PLAN REVIE`V � Yes � No SEtiVE.R CONNECTION <br /> STATE SURCHARGE Yes � No �VATERCONNECTIO�,T <br /> INVESTIGATIOivT FEE Yes No �/ PARK FEE <br /> SAC <br /> y�s �,Ta —� SITEINSPECTION <br /> Number of SAC�Units OTHEA (specify) <br /> ZONi�i tG CH�.CK. LIST Zoning Districr. A�� GH AN�� . <br /> Fire Dep�rtment: <br /> Post Office: School District: � <br /> Lot Area; Sq.ft. <br /> Acres Wid�h Depth <br /> Survey Submitted; Yes No Dace oE Survey: _ <br /> Proposed Setbacks': <br /> Fronc(Lake): Righ�Side: , <br /> Rear(Streetj; Left Side: <br /> Adjacent Structures: Ve[1and: <br /> Buil�ling Hei�c: Det. Hgt, P a'�`Hg�. <br /> Lot CoveraQe: <br /> fjv� Cv"liuCu r�Y?�G�,r�l Tlat?; ' <br /> Gradin�: S�aff Approval D�te; � • <br /> Sep�ic: S�af[ Approvzl Dace: E;�: <br /> Zoain� Fuz: R Resolu:ion: n Resolu:ion Date: <br /> Shetelzr.d District: ���r�veraQe: <br /> �vg. Setback: BluEf Se back: <br /> Eustino Proposed <br /> Hz�dcover; 0-75' <br /> 7�-25Q' <br /> 2�0-50a' <br /> �00-1 Ct,�'J' — <br /> �g• r` �'p�inri� Apnr;vZ: <br /> �:?-�'COY�. �;�_ .,�:C� .,��'_.:��.. :z= . �- - . , <br /> F.E��L�KS (in hou�e,;: <br />