HomeMy WebLinkAboutBLD1998-00200 1 •
JEFFERSON COUNTY PERMIT CENTER, 621 SHERIDAN ST, PORT TOWNSEND WA 98368
MANUFACTURED HOME INSTALLATION PERMIT APPLICATION
P NEW BUILDING 0 REPLACEMENT
SIZE � (00 C 1PC.k U) 1 i. E1 (1.9G5ne(T)
YEAR I coy
MAKE RcbmIC.1Q
COST -7.5• ' -r T (
BEDROOMS: BATHROOMS:
1 /
EXISTING ) EXISTING
PROPOSED .5 PROPOSED 3
TOTAL -- TOTAL J
TYPE OF SEWAGE DISPOSAL: WATER SUPPLY:
0 SEWER 0 COMMUNITY SYSTEM 1 'PRIVATE WELL 0 TWO PARY WELL
INDIVIDUAL SYSTEM [Conventional 0 PUBLIC
PERMIT # SEP 9j 7-c)130 0 Alternative Name of water system:
IF WATERFRONT PROPERTY,/
CX-, P7 '
DISTANCE TO DA'NK"U7' IIGH WATER LINE 'E7I ft BANK HEIGHT ft
SIGNATUREiilt DATE �---5— !r
NAME (PLEASE PRINT) S�'�VJ cN 4 (i-li) C 'cs'I...I
FOR OFFICE USE ONLY
BASE FEEs1 RECEIPT # 1`4J2
ADDITIONAL SECTIONS 4" CA /CK /orb
STATE SURCHARGE " DATE (-1 / '
SUBTOTAL / 9 6/9
POTABLE WATER 7' .1 .
911/ROAD APPROACH 5-6
TOTAL H:\HOME\PLNCNTR\FORMS\MOBILEAP.5/97