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. <br /> � <br /> CHECK OFF LIST FOK ISSUANCE OF PER,�1%fITS <br /> FOR OFFICE USB ONLY <br /> ADDRESSORLEGAL: 3�`-�S Iv�C�+�S��� p2- <br /> PID: <br /> DESCRIPTION OF Yf�ORX: Rx.��� <br /> ZOtYItVG REVIE tv B X':-----�-�'�r-------------r-r------------DATE APPRDVED: �''S—O-S � <br /> B UILDItYG RE VXE N�B Y' �-�- ^� �-- Dr•.l TE APPR O 6'ED: �-��'- ^ <br /> ----------------------------------------------------------------------------------------------- --------------a�----- <br /> FEES TO BE CH.�lRGED: h•Iisc. Fees Calc�cfated By: <br /> PERh�tIT Yes _� No <br /> PLAtV RET�IEGV Yes � �Vo SELVER GOtWt ECTIO�V <br /> STATE SURCHARGE Yes�� tVo tiVATER GO��NECTIO�V <br /> � Il�!'VESTIGATIOtV FEE Yes �Va� PA�K FEE <br /> SAC ,Yes 1Vo � SITE tNSPECTION <br /> Ncunber of SAC U�iits OTHER (specify) <br /> ----------------------------- <br /> ---------------------------------- <br /> Z'O�VI[YG CHECK LIST Zor�irag Dish•ict: �/O G/-f'K�'i`�� <br /> Fir•e Departrrierrt: Post Office: Scicaol Disn'ict: _.. <br /> Lat.�lrea: Sq.ft. Acres ��idth Depth <br /> Su�-vey Subrriitted: Yes No Date af Su�vey: — <br /> Proposeci Set6acl;s: <br /> Front(LRh.e): Right S e: <br /> Rea�•(Sh•eet): Left Sid <br /> Adjncent Str•uctur•es: 6Petland: <br /> Builcling Height: Def. Kgt. Peak Kgt. <br /> Lot Coverage: � <br /> Gracling: Stnff:tpp►'aval Date: By: Coa�ncil Approval DRte: <br /> Septic: Staff.dpproval Date: BY� <br /> Zorci�tg File: # _ Resalution: # Resaliction Date: <br /> SJto�•elancl Disd�ict: <br /> Avg.5etbnck: Bluff tback: Lot Coverage: <br /> � Esisti Proposecf <br /> Hardcover: 0-75' <br /> 75-250' ' <br /> 250-500' ---�— , <br /> 500-!000' <br /> Har•dcover Variance Rec�ccirec{: Yes No Date of Coa�ncil Approval: <br /> .REIVIARK'S(iri lsoccse}: <br /> ;31 , <br />