HomeMy WebLinkAboutFYFE BLK G LT 2APPLI; eNT FILLS OUT UPPER HA ONLY
Proms rty Owner 7zl/v1/%
Phone
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Mailing Address kJ,� ��' 7 //ff/� i �f%jrL' Zip Code
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Buyer
Address 1�1 Zip Code
Lending Institution � ,y �
CJJ�J'�%!%�/?/fly /J���
Phone
Address 7 /%2jj/ ,� j�f% (jam[ Zip Code
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Realty Co. & Agent /� /_ ice(/ �rV j /%
Phone
Address Zip Code
Legal Description
Street Location
Type of Residence
Single Family
❑ Multiple Family No. of Bedrooms
❑ Other
Water Supply
-�K Individual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Community
For wells drilled prior to that date, give well depth (attach log if available).
ElPublic Utility
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Sewer Disposal G /�
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❑ Individual Year Individual Installed:
..EiZ Public Utility When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time .1
Ac' o
Date
Date
Date t a' ` 4
Date ++ 11 L
Inspector
Inspector
Inspector
Inspector D COLO
Field Notes: DEPT. OF HEALTH t;
ENVIRONMENTAL PROTECTION
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MAR
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RECEIVED
( `APPROVED BEDROOMS 'CONDITIONS OIF APPR VAL
( ) DISAPPROVED j
( CONDITIONA/L APP
DATE VAL'
BY: /r✓� ^ ^
W�
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Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
72-023 (3182)