Three completed and executed copies of this application supplemented with applicable required information must be filed with the City Manager’s office. Such applications will be assigned a file number and distributed to the Health Department for review and comments. Separate application shall be submitted for each lot subdivided. One copy of the application, together with the actions taken by the City Planning Commission, will be returned to the applicant or his or her agent.
NAME OF APPLICANT OR AGENT _________________________________________________________________________ ADDRESS _________________________________________________________________________ CITY __________________________________________________ STATE ___________ ZIP CODE _________________________________________________________________________ TELEPHONE _________________________________________________________________________ NAME OF GRANTOR _________________________________________________________________________ ADDRESS _________________________________________________________________________ CITY _________________________________________________________________________ STATE _________________________________________________________________________ ZIP CODE _________________________________________________________________________ TELEPHONE _________________________________________________________________________ Township of transfer _________________________________________________________________________ Section _________________________________________________________________________ Size of Parcel _________________________________________________________________________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (For use of the Nelsonville City Manager) Date Received _________________________________________________________________________ Date Reviewed _________________________________________________________________________ Approved _______________________________ Disapproved_______________________________________________ _________________________________________________________________________ Nelsonville City Manager Comments: _________________________________________________________________________ _________________________________________________________________________ ___________________________________________________________________________________________________________ (For Health Department Use Only) Date Received: _________________________________________________________________________ Date Reviewed: _________________________________________________________________________ Approved _____________________________ Disapproved_______________________________________________ Supervising Sanitarian: _________________________________________________________________________ Comments: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ (For Use of the Nelsonville City Planning Commission Only) Date Received _________________________________________________________________________ Date Reviewed _________________________________________________________________________ Action: Fees Due $ _________________________________________________________________________ Fees Paid $ ______________________ Date Paid__________________________________________________ |
Comments: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ President |
(Prior Code, Chapter 23.12, Appendix B)