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<br />SHGR'P 5175UIVISION APYLiCATIOY -7 ,' _ ;
<br />tinnhomish Coun[y Planning Dc-par[:nenC . �
<br />Snuhomish County Cour[ Flouse
<br />liverett, Washington 98201
<br />Yhune: 259-9�11 (Home)
<br />Nh;•tE:_N,.7. Verbeek PNO�vF,: (8usiness) �
<br />AD�Rt:'_S: 8n31 Old Fhay, 1 A Snohomivt�
<br />Sec. 1_'hrp, 28 Etange 5 _ 7.oning oE Yro,�ecty ��9�(�j} __
<br />Sour x of Wa[er Supply
<br />Name of War.ei Dis�rict; if any
<br />hfethod of �e4age Disposal DrainEileda
<br />NOTG: Health DLstrict signature does not indicate sui[ability of thesa lote
<br />for septLc s�stems. This review,applies only to the plat as a whale, an� [hat
<br />sewage dispo:al requirements for each lot shall !�e subject to soil analysi; as
<br />determined b; tests performed on indivldual lots,
<br />Name of Sewe. District, if any
<br />To be signed by tha applicant;
<br />I herehy certi.:y that ehe legal dascription of the 7.and being divided
<br />and accompen ing thiis application shovs the entire contiguous land in which
<br />there is an nterest by reason of ownership, contract for purchase, earnest
<br />muney agreem nt, or op[ion by any person, fitm or corporation in any manner con-
<br />nected with he development, and listed below aYe the names, addresses, and
<br />telephone nu• bers of all such persous, firms or corpocations. (I£ same as
<br />applicant na ed ab�ve, 'lea�e hLank.) '
<br />{1) Name
<br />.4ddress
<br />(2) Nime
<br />Addr
<br />Phone:
<br />Phone•
<br />± i( c.� �n �.� i v (��, �
<br />(Sign tuce of ,pp icant) (Date Proparty Acquirrd)
<br />-----------------------------------------------------------------------------------
<br />VIc'INITY MAP '
<br />(Please provide s�ifiicie�c �etail to;allow field inspector to locate aite)
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