CRESTVIEW LT 7A - ZCPBUILDING DEPARTMENT - KODIAK ISLAND BOROUGH
(APPLICANT TO FILL IN ALL INFORMATION WITHIN
APPLICATION FOR BUILDING PERMIT AND CERTIFICATE OF OCCUPANCY c/o-753p,
HEAVY LINES. PLEASE PRINT, USE BALL -POINT PEN, AND PRESS FIRMLY.)
SUBDIVISION /SURVEYuG�+$ 22iQ
e2 STh aft s t3
LOT NO. BLOCK NO,
CLASS AND SCOPE OF WORK
NEW
DEMOLISH
32 Z U E-
STREET ADDRESS
NEAREST CROSS STREET
ALTERATION
ADDITION
X
USE OF BUILDING
REPAIR
MOVE
BUILDING PERMIT NUMBER
i4,
DATE ISSUED J
E /
S
SIZE OF BUILDING J /oO . HGT 22r
NO. OF ROOMS
6
FLOORS 2.
NO. OF FAMILIES
NAME
142()4 Ib
MAILING ADDRESS
NO. OF BUILDINGS NOW ON LOT
VALUATION: (BASIS)
6,�� -7552
AMOUNT
USE OF BUILDINGS 5F R.
i
BLDG PERMIT
PLAN CHK FEE
eraw-
TOTAL
INSPECTION SCHEDULE
0 "Po, 234z-- ca4-37z9
0 CITY, STATE TELEPHONE
iA-/. 44._
NAME
1
H �
U W
W W
Z
2-
Z
Q W
SIZE OF LOT
WATER: PUBLIC X PRIVATE
BUILDING
PLUMBING
ELECTRICAL
FOUNDATION
ROUGH
SEWER: PUBLIC PRIVATE
SPECIFICATIONS
FRAME
SEPTIC TANK
PLASTER /BD
SEWER
FOUNDATION
EXT
TYPE
ADDRESS
DEPTH IN GND
HGT FIN GRADE
CITY, STATE
P.T. PLATE (SILL)
STRUCTURAL
SIZE
PIERS
9"05
3z,"
ll ''�Z (c
DM
SPA. SPAN
STATE LICENSE NO.
GIRDERS
JOISTS 1ST FLR.
NAME
ADDRESS
5 0 9S-r"
To, 1o'(
CITY, STATE
4Z.
Gobi 14e1 4kC.
STATE LICENSE NO.
JOISTS 2ND FLR.
foc12
ZX1O
JOISTS CLG
EXT STUDS
INT STUDS
ROOF RAFTERS
TRUSSES
2Xc.4
2ycl
FLUES
GAS
FINAL
FINISH
ROUGH
FINISH
FIXTURES
MOTORS
FINAL
EACH OF THE ABOVE INSPECTIONS MUST BE REQUESTED AND THAT
WORK APPROVED PRIOR TO ANY ADDITIONAL WORK PROGRESSING
BEYOND THAT POINT, AS REQUIRED BY UBC SECTION 305. FOR EACH
INSPECTION, 24 HOURS NOTICE IS REQUIRED. TELEPHONE THE KODIAK
ISLAND BOROUGH ENGINEERING DEPARTMENT, 486 -5736. EXT. 273.
9•S
ll/5-
/(01 ` %'Z 9®
g' qZ 9
`%,�! 67
24"
(FOR OFFICE USE ONLY: CIRCLE)
1. OCCUPANCY GROUP
A B E H
DIVISION 1 2 (s 4 5
2. TYPE OF CONSTRUCTION
FR 1 -HR. N H.T.
1
BEARING WALLS Zy(I
INSULATION, FNDN I�
NOTES:
INSTALLATION OF (MINIMUM) 18 -INCH BY 20 -FOOT CULVERT IS REQUIRED
AT EACH DRIVEWAY ACCESS TO THE PROPERTY.
SANITATION PLAN APPROVAL BY AN ADEC- CERTIFIED INSTALLER 15
REQUIRED PRIOR TO ISSUANCE OF A BUILDING PERMIT WHERE PUBLIC
WATER AND /OR SEWER 15 NOT AVAILABLE FROM A CERTIFICATED
MUNICIPAL SYSTEM.
INSTALLER'S PLAN APPROVAL RECEIVED
INSTALLER
WALLS ROOF /CLG
SHEATHING, WALLS /EXT
FI
I/z. II
ROOF *JIM( FLOOR 2x/_ r
NISH, EXT WALLS W
ROOF ComP SJ //!%(r
FLUES, FIREPL WOOD HTR
PRIOR TO THE ISSUANCE OF A PERMIT, EITHER THE OWNER OF THE
PROPERTY OR HIS AUTHORIZED AGENT MUST SIGN THIS APPLICATION OR
GRANT OTHER WRITTEN PERMISSION FOR THE DESCRIBED WORK TO BE
PERFORMED.
TAX LOT NO
OWNER
l " J tL.J5 \b ATE
PER
OWNERSHIP TRANSFERRED, IN PROCESS, TO:
KITCHEN WATER HTR
FURNACE, TYPE
I HEREBY ACKNOWLEDGE THAT I HAVE
READ THIS APPLICATION, THAT IT I5
CORRECT, AND THAT I AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS
REG , ATING BUILDING CONSTRUCTION.
APPLICANT
CLOSING DATE, DEED RECORDED
PER
(BY)
PPROVED, BUILDING OFFICIAL
PLOT PLAN
(A SITE PLAN MAY ALSO BE REQUIRED)
REAR PROPERTY LINE
SIDE PROPERTY LINE
FRONT PROPERTY LINE
STREET
SIDE PROPERTY LINE
NOTE: APPLICANT SHALL SHOW BUILDING SETBACKS
FROM PROPERTY LINES, AS PERPENDICULAR DISTANCES
FROM PROPERTY LINES TO BUILDING. DIMENSIONS OF
STRUCTURE SHALL BE SHOWN ON THE PLAN.
ZONING CODE COMPLIANCE
ZONING DISTRICT
TYPE OF OCCUPANCY
NO. OF STORIES
TOTAL HGT
AREA OF LOT
SETBACKS FROM PROPERTY LINES:
FRONT
REAR
SIDE (L) SIDE (R)
REQ'D OFF - STREET PARKING
C.U.P. OR VARIANCE
APPROVED, ZONING OFFICER
BY
White copy: File
Yellow copy: Building Permit
Pink copy: Applicant
ZONING COMPLIANCE PERMIT
1. PROPERTY OWNER /APPLICANT
Kt Island Borough
-Community Development Department
710 Mill Bay Road, Room 204
Kodiak, Alaska 99615
(907)486 -5736 Ext. 255
Zoning Compliance #:
Name:
Address: to)(
Telephone:
2. LEGAL DESCRIPTION OF PROPERTY
Street Address: "------.4---9.--- 'f ice/
Minimum lot width:
Average lot depth: Average lot width: 95-1
Lot, block, subdivision: tor ' 7 A
Use and size of existing buildings on the lot: . , R 2
V\-/
Survey, other (e.g. township /range):
Maximum projection(s) into required yards: NJ 44,_ "rckt.5 Pelt ( r
Maximum buildin g hei ht:^9D �� 3. � I
®Fsp-ce "'IP4-I Maximum lot coverage:
bj CQ 7 1
Number and size of parking spaces required:
Tax code #: _ f 2 7 37 s
3. DESCRIPTION OF EXISTING PROPERTY
Zoning: 2 Q., Square footage of IotO9®, /6?
Minimum lot width:
Average lot depth: Average lot width: 95-1
Lot depth to width ratio:
Use and size of existing buildings on the lot: . , R 2
Sides: cr, c ( M Ir--1 Additional Setbacks:
Maximum projection(s) into required yards: NJ 44,_ "rckt.5 Pelt ( r
4. DESCRIPTION OF PROPOSED ACTION (attach site plan)
L0()( tat M7tv (Co/J L-6&'-(St 1 c idoa, S-E y -
l wt (26,0-7-- AxiD S t
Ai4D 44JD L -»
5. ZONING REQUIREMENTS FOR NEW CONSTRUCTION
Type of structure(s):
Minimum Setbacks — Front: 05t m ti. Rear: ,.9:51 ( Al 1/...j
Sides: cr, c ( M Ir--1 Additional Setbacks:
Maximum projection(s) into required yards: NJ 44,_ "rckt.5 Pelt ( r
Maximum buildin g hei ht:^9D �� 3. � I
®Fsp-ce "'IP4-I Maximum lot coverage:
,J�A
Number and size of parking spaces required:
Off- street.loading requirement:
Plat related requirement(s):
N
Other (e.g. zero lot line):
6. CONSISTENCY WITH COASTAL MANAGEMENT PROGRAM
Applicable policies:
Proposed action consistent with Borough Coastal Management Program — Yes X. No
Proposed action conflicts with policies (note policy and describe conflict):
Conditions attached to Consistency approval to mitigate conflicts noted above:
7. APPLICANT CERTIFICATION
I hearby certify that I will comply with all provisions of the Kodiak Island Borough Code and that I have the authority to certify
this as ownerentative of the owner, of the property(s) invol
III
i.
X401
8. SUPPORT DOCUMENTS ATTACHED
ISite Plan:
9. BOROUGH STAFF AP • ROVA
Staff Approval:
Signed
Title
Date-
Other:
Building permit #:
ORaJahraltrAgIataitatAtArdaiNatANAVIA004AVAKIRMVOACAVAM,ArtaWaratkriaVahr.
\ \ \ \ \ \ \ \
. •
aataataragaratataMPAWArAarraVarw,vear,ratamAtr.r,rataavoraAROAkt, AtatlataWaraaraWabraraArAtalarabekraa,AgsrA
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, Classification
U se
Addition, Garage (SFR) Bldg. Permit No) 899,4anuary 24, 1985 7. .
a A 6,6,6At MA WM% /MAI AAA& eq,,A.8.2S ISAWAAVVA.4 A, A A e A.ALS.A.A.A.A.A‘AWA.A.A.AVAAWALAWA
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,
Designed and printed by Page Photo & Printing, Kodiak, Alaska.
BUILDING DEPARTMENT - KODIAK ISLAND BORGOGH 1 APPLICATION FOR BUILDING PERMIT AND CERTIFICATE OF OCCUPANCY
(APPLICANT TO FILL IN ALL INFORMATION WITHIN HEAVY LINES. PLEASE PRINT, USE BALL-POINT PEN, AND PRESS FIRMLY.)
SUBDIVIS
ON/SURVEY VtA,A,
OT O. BLOCK NO.
STREET ADDRESS
CLASS AND SCOPE OF WORK
NE
DEMOLISH
ALTERATION
REPAIR
BUILDING PERMIT NUMBER
ADDITION
OVE
USE OF BUILDING
SIZE OF BUILDING
NEAR
ST CROSS STREET
NO. OF ROOMS
GA_Afte_L--
.1.1k,g4
HGT
FLOORS
NO. OF FAMILIES
1
z
NAME
1.4
AILING ADDRESS
.0, e-d, X' .Z3 "lg.
NO. OF BUILDINGS NOW ON LOT
USE OF BUILDINGS
SIZE OF LOT
gto
WATER: PUBLIC
DATE ISSUED
2 9-
VALUATION: (BASIS)
V 14'(ert 04- Cies Y--
AMOUNT
000
BLDG PERMIT FEE
6
PLAN CHK FEE
30
TOTAL
l°1
7 6
INSPECTION SCHEDULE
BUILDING
PLUMBING
EL CTRICA
FOUNDATION
ROUGH
ROUGH
CITY, STATE TELEPHONE
SEWER: PUBLIC
PRIVATE
SPECIFICATIONS
FRAME
SEPTIC TANK
FINISH
PLASTER/BD
SEWER
FIXTURES
NAME
FOUNDATION
EXT
PIERS
FLUES
TYPE
446 Pot,
4T/
FINAL
GAS
FINISH
MOTORS
FINAL
ADDRESS
DEPTH IN GND
HGT FIN GRADE
CITY, STATE
P.T. PLATE (5
STRUCTURAL
SIZE SPA.
SPAN
EACH OF THE ABOVE INSPECTIONS MUST BE REQUESTED AND THAT
WORK APPROVED PRIOR TO ANY ADDITIONAL WORK PROGRESSING
BEYOND THAT POINT, A5 REQUIRED BY UBC SECTION 305. FOR EACH
INSPECTION, 24 HOURS NOTICE IS REQUIRED, TELEPHONE THE KODIAK
ISLAND BOROUGH ENGINEERING DEPARTMENT, 486-5736, EXT 273
STATE LICENSE NO.
GIRDERS
JOISTS 1ST FLR.
NOTES:
INSTALLATION OF (MINIMUM) I8-INCH BY 20-FOOT CULVERT IS REQUIRED
AT EACH DRIVEWAY ACCESS TO THE PROPERTY.
cc
i-
v
1-
z
NAME
ADDRESS
ea. / e
JOISTS 2ND FLR.
JOISTS CLG
EXT STUDS
INT STUDS
CITY, STATE
/44(
STATE LICENSE NO.
/9 HgotS
ROOF RAFTER
TRUSSES
AOC
2y4
2W/
.2.0.1.
SANITATION PLAN APPROVAL BY AN ADEC-CERTIFIED INSTALLER IS
REQUIRED PRIOR TO ISSUANCE OF A BUILDING PERMIT WHERE PUBLIC
WATER AND/OR SEWER IS NOT AVAILABLE FROM A CERTIFICATED
MUNICIPAL SYSTEM.
INSTALLER'S PLAN APPROVAL RECEIVED
INSTALLER
(FOR OFFICE USE ONLY: CIRCLE)
1. OCCUPANCY GROUP
A B E H
0
1
DIVISION 1 2 CD 4 5
2. TYPE OF CONSTRUCTION
FR
11 111 IV
1-H R.
H.T.
BEARING WALLS
PRIOR TO THE ISSUANCE OF A PERMIT, EITHER THE OWNER OF THE
PROPERTY OR HIS AUTHORIZED AGENT MUST SIGN THIS APPLICATION OR
GRANT OTHER WRITTEN PERMISSION FOR THE DESCRIBED WORK TO BE
PERFORMED.
TAX LOT NO c‘? 7z 160e90 o 7 1 D AT E ittel,-4..- r b--....
INSULATION, FNDN
OWNER VA CA (.2)4 C Fria-pct PER PO!
FINISH, WALLS le- I?
SHEATHING WALLS/EXT
ROOF /1°I.447-
FLOOR 4.,
ROOF/CL
77-// A/Wt-g
re-4-e...
- SO
//OWNERSHIP TRANSFERRED, IN PROCESS, TO:
PER
eft VALLS CLOSING DATE, DEED RECORDED (BY)
ze-
ROOF /74411 5)44441 ce
6 2 9- t ga,a/a 6:GiCkiLPY1 4'..5:6 7
FLUES, FIREPL W00:4'fHTR OW
KITCHEN WATER HTR
FURNACE, TYPE IF
I HEREBY ACKNOWLEDGE THAT I HAVE
READ THIS APPLICATION, THAT IT IS
CORRECT, AND THAT I AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS
REGULATING BUILDING CONSTRUCTION.
0/04°h/ei,ep
APPLICANT
qx/V.-:-/.2‘' c
Ckdre,oe elvm) I-1)4,011m g-'r--
‚J 4 If
APPROVED, BU LD1NG OFFICIAL
A
BY Zfr/j ,aeiA
PLOT PLAN
(A SITE PLAN MAY ALSO BE REQUIRED)
REAR PROPERTY LINE
SIDE PROPERTY LINE
FRONT PROPERTY LINE
STREET
SIDE PROPERTY LINE
NOTE APPLICANT APPLICANT SHALL SHOW BUILDING SETBACKS
FROM PROPERTY LINES, AS PERPENDICULAR DISTANCES
FROM PROPERTY LINES TO BUILDING. DIMENSIONS OF
STRUCTURE SHALL BE SHOWN ON THE PLAN,
ZONING CODE COMPLIANCE
ZONING DISTRICT
TYPE OF OCCUPANCY
NO. OF STORIES TOTAL HGT
35-/
AREA OF LOT 20 (6'9' ,'-
SETBACKS FROM PR PERTY LINES: A.
FRONT <>76**- REAR /10
SIDE (L) SIDE (R)
REQ'D OFF-STREET PARKING,2 6sKz,4 40_46,60.
C.U.P. OR VARIANCE
APPROVED, ZONING OFFICER
BY&Ld
, BUILDING DEPARTMENT --- CITY / BOROUGH OF KODIAK
' - Applicant to fill in' between heavy lines,
APPLICATION FOR BUILDING PERMIT AND CERTIFICATE
OF OCCUPANCY
BUILDING ADDRESS
—r-
CLASS
NEW
OCALITY
ALTERATION
L 4 pin
NEAREST CROSS ST.
NAME
ADDITION
F WORK
DEMOLISH
REPAIR
MOVE
BUILDING PERMIT NO.
5'
DATE ISSUED
/ 2 3
USE OF BUILDINGSt
SIZE OF BUILDING. j/
HEIGHT
MAIL ADDRESS
0
0 IC
NO. OF ROOMS
7
NO. OF FLOORS
1-41 t.a
- Z
U
Z
1.4
CITY
NAME
ADORE 5
CITY
rPel- T,2-1
0 I
67c&-04
STATE LICENSE NO
NAME
s
NO, OF BUILDINGS
VALUATION
BLDG. FEE
/37
e 0
PLAN CHK. FEE
TOTAL
c6-
a o
NO. OF BUILDINGS NOW ON LOT
BUILDING
PLUMBING
ELECTRIC
NO. OF FAM E
FOUNDATION
ROUGH
ROUGH
IZE OF LOT
e. 47
FRAME
SEPTIC TANK
FINISH
USE OF BLDG. NOW ON LOT
PLASTER
SEWER
FIXTURES
SPECIFICATIONS
FLUES
GAS
MOTORS
ADDRESS
FOUNDATION
'ANAL
FINISH
FINAL
MATERIAL
EXTERIOR,
PIERS
CITY
-
IDTI-I OF TOP
I DTH OF BOTTOM
EPTH IN GROUND
/
z
*Z-4/
z
R.W. PLATE (SILL)
STATE LICENSE N
SIZE
SPA....
SPAN
LU
ESCRIPTION
SUBDIVISION
L)/teUJ 5p
GIRDERS
.x / C:3
JOIST 1st. FL.
OIST 2nd. FL.
(
LOT NO.
BLK.
OIST CEILING
/6,r1
EXTERIOR STUDS
.2—
DO NOT WRITE BELOW THIS LINE
1. Type of Construction
I, II, Ill, IV, V, VI
2. Occupancy Group A, B, C, D, E,
F, G, H, I, J Div, 1, 2, 3, 4,
3. Fire Zone 1 2 3 4
INTERIOR STUDS
ROOF RAFTERS
EARING WALLS
COVERING
EXTERIOR WALLS 47/5 I ROOFA5 S2;
INTERIOR WALLS //,' 0'67 ce..)1? REROOFING
.FLUES
FIREPLACE
(t
, FL. FURNACE
K TCHEN WATER HEATER
FURNACE
c
GAS OIL
1 hereby acknowledge that I have read
this application and state that the
above is correct and agree to comply
with all City- Ordinances and Sta
Laws regul g building construc
Applican f
Approved: CHIEF BU LDING OFFICAL
By
ZONING DISTRICT
3NI1 A.LH dO2dd
PLOT PLAN
/2- I
IjJ
3NI1 h12:13dO2:id
STREET
PLANNING & ZONING INFO.
TYPE OF OCCUPANCY
NUMBER OF STORIE
STICI
AREA OF LOT
TOTAL HT.
FRONT YARD SETBACK FROM PROP. L. NE
4.2
SIDE YARD SETBACK FROM PROP. LINE / 5-6
REAR YARD AS I 74--
Approved: ZO ING ADMINISTRATOR 7/23ine
By
BUILDING DEPARTMENT — CITY / BOROUGH OF KODIAK
Applicant to fill in' between heavy lines..
APPLICATION FOR BUILDING PERMIT AND CERTIFICATE
OF OCCUPANCY
BUILDING ADDRESS
-40-7- 7
LOCALITY �1 6,63 \ , •
NEAREST CROSS...a.,
NAME /
Z
0
MAIL
F
U W
• W
Z
U O
• Z
Q W
ADDRESS Igv x 81
CITY /4 TEL. NO. OF BUILDINGS
NO. OF BUILDINGS NOW ON LOT
NAME
CLASS 5E -WORK
NEW
DEMOLISH
ALTERATION
REPAIR
ADDITION
MOVE
BUILDING PERMIT NO.
USE OF BUILDING Q' /00 `-E.
SIZE OF BUILDING Sit V
NO. OF ROOMS
NO. OF FLOORS
ADDRESS
CITY
HEIGHT 7...5 (
9
DATE
ISSUED
//3/78 0
m
1
cc z
VALUATION
3
BLDG. FEE
S
o
PLAN CHK. FEE
TOTAL
/ -7
i�C ✓ee/ r . gicks. NO.
;Q> $' /
/�oq./6a-
STATE LICENSE NO.
BUILDING
PLUMBING
ELECTRIC
OF FAMILIES
SIZE OF LOT
moo, /2U +
FOUNDATION
ROUGH
ROUGH
g,42
FRAME
SEPTIC TANK
FINISH
USE OF BLDG. NOW ON LOT
PLASTER
SEWER
FIXTURES
SPECIFICATIONS
FLUES
GAS
MOTORS
FOUNDATION
FINAL
FINISH
FINAL
NAME
ADDRESS
CITY
c
STATE LICENSE NO.
MATERIAL.
EXTERIOR,
PIERS
WIDTH OF TOP
WIDTH OF BOTTOM
DEPTH IN GROUND
R.W. PLATE (SILL)
/
2
4
.7L %rr
Z
,3s) ,CCG
SPA..
SPAN
J
0
J
DESCRIPTION
SUBDIVISION
GIRDERS
JOIST
lst. FL.
JOIST 2nd. FL.
7X/
LOT NO.
BLK.
sg
JOIST CEILING
EXTERIOR STUDS
DO NOT WRITE BELOW THIS LINE
I,- ''' 1. Type of Construction
I, II, III, IV, V, VI
2. Occupancy Group A, B, C, D, E,
F, G, H, 1, J Div. 1, 2, 3, 4,
3. Fire Zone 1 2 3 4
INTERIOR STUDS
ROOF RAFTERS
Z /0
f rU
/76
/
/r
/1o/I
zerr
Z4' u
BEARING WALLS
COVERING
EXTERIOR WALLS A T /_I ROOF2s ��f4
INTERIOR WALLS t(L C (.L) REROOFING
FLU ES
FIREPLACE
n� J
FL. FURNACE
2 " ZA-'S.
KITCHEN WATER HEATER
FURNACE
GAS OIL
I hereby acknowledge that I have read
this application and state that the
above is correct and agree to comply
with all City - Ordinances and State
Laws reg l g buildionstr n.
Applica'�
,° 7e : g*, /I/ gS
Approved: CHIEF BUILDING OFFICAL
By.
PLOT PLAN
A
H
SETBACK
3NI1 Al2l3dOHd
STREET
PLANNING & ZONING INFO.
ZONING DISTRICT a
TYPE OF OCCUPANCY
NUMBER OF STORIES
AREA OF LOT 26
FRONT YARD SETBACK/FROM PROP. INE
SIDE YARD SETBACK FROM PROP. LINE
REAR YARD
Approved: ZONING ADMINISTRATOR
</
TOTAL H
/ Z' .L.. (
540,ig'oe,4
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CC.ESS EASEMENT
06
00 '
,9°
, le°
/
64.49'
a° 55' oo-
Rz380.00'
L:27.08'
r/3.5"5"
ra
0
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/08.10'
0
0
S 6'3° 00'00- w
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UNSUBD/V1DED
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G2. 33'
.S.S 3210
4. 0 9`
2. 50
4, 23°27'37-
'53
/3°4'6 •
370,00'
1-
SITE APPLICATION
PRIVATE SEWAGE DISPOSAL SYSTEMS
ISLAi;ID. BOROUGH.
Owner of Property /� 0,6¢5f/19Gt Sf 4"°"✓
pAa ling Peeress
Legal Description of Property:
-lock
Location
Subdivision �f��3T�iiZ
:: ze of Lot (SQ . Ft. )
;_64 C,9/4/67
J,.
Type of PErmit Requested
1•11311er Suppiy:
Semi Public
Zone
Acres
7L
U. S. Survev3,2(g-
tiivc155-
Private
Type of Sewage Disposal System:
Privy Cesspool Septic Tank Size lj p0 ,y1
No.
Construction Pula serial: ;
Effluent Disposal.
(. ) No. Size (s)
Absorption Field Trench (s) Sq.Ft. Lit
F ter Bed
Other
Other (explain)
Sq.Ft. Ft. Depth
Size 3 Type of Sewer Lines
COMMENTS:
:Applicant:
Address
Phone
,il %mssf< /3
Ai-sm ch&-A Pv
_FoX Tl
Health Official
Date
.• "
7-e
.‘ :flu d.C.
1 All q /