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PUE.•CITI'-COUNTY HEALTH DEPART*fEN1 • <br />Application for Preliminary Investigation of Property <br />for Suitability of Individual Sewage Disposal Systems <br />Name of Applicant: ~'tl,lTt EtJ'fbL MATEh2lAJr~~R~ CZRAhSrr Ml~(~Phone c~-~_~', <br />Mailing Address: 215 W . We.CYFl2 L1=-~. C}~CAf~O IL (ocCoDC.a-I~_°J <br />Street Address of Property for which Clearance Letter is being requested: <br />54'} 5 W HW`C °~ <br />Legal Description: TFiE t~LoRTN "l~2 FEET OF Ttit. EAST 91~i FC-E'-C Off' <br />TuF 'tiI'E ~!4 OF ~~CTI[ON ?fa-~ 'fC]~~Sd-IIP Zn C+CilT4~ r <br />RhKGE CrfA wECT p~ T4-IE Cn~H P.'1~1 <br />Type of Zoning Action being requested: Sp6C_IaL L15E PF2.MlT <br />Size of Original Property: <br />Size of Property to be split off. (If variance is to divide the property): <br />~Cc:1?~ A('_~n_S <br />Type of Structure to be built. (Commercial or Residential): Cep u~f~rll~L <br />Type of i.ater Supply to be used: ~pq~,p pF II~~AT~R Wf1R~S <br />A PLOT PLAN MUST BE ATTACHED SHOEING THE FOLLOWING: (May use the back side of this <br />application) <br />1. Detailed directions for locating property. <br />2. Accurate boundary measurements. <br />3. Location of existing and proposed structures on property. <br />4. Location of proposed and/or existing sewage disposal system. <br />5. Location of water supply and/or to property. <br />6. Location of all wells and/or within 150 feet of property. <br />Is Processed Application to be picked up X Or Mailed <br />+Signature of owner or agent j;„ ~~5~~„f~ ~,f~ly- Jd(o,{-~ Date L}"~_~f'7 <br />This is NOT a permit for installation. This application, and any action precipitated, are <br />for the sole purpose of recommendation on a proposed Zoning Action. <br />7~3i3~XXXXX};.}iXX.}QiIOCR}i%R}:a}:XXX};)t_~?:}i}:}OiR]:X]C.~X};XX.iskXXXR lfkl'}~XXaXXX.~Ui}i]i.\}CXXXX7i}:RX3:X}:XX.}{}iX.X}:X}:XXXX.YXX]t <br />(Do Not [,'rite Below - For Department Use Only) <br />HEALTH DEPARTMENT COI•QfENTS: <br />Pueblo City-County Health Department <br />Approval By: d ~~,,,~~~„a~.~~. <br />Date:" 5/-/U-9 ~ <br />n ~~ -~] C <br />j ,``, <br />J- ArR % ~ 1 <br />r: -:•i <br />1/82 <br />