HomeMy WebLinkAboutACSA199400002 Application 1994-09-14 • 'ATTACHMENT Al
APPLICATION TO AMEND THE A18� County of Albemarle
Department of Planning and Community Development
SERVICE AUTHORITY ° tr, 401 McIntire Road
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JURISDICTIONAL AREAS %fr; I ,P 804 296-5823Charlottesville,VA 22902-4596
APPLICANT Name: /W i5 /9- /' 3 h
Signature: ! Phone:/1 2`7 3 -3//
Address: 'O ��' : 2 y4- -f/,5'/
6%/ del 04 2L 903- yz�/
CO-APPLICANT Name (or agent, if any):
Signature: Phone:
Address:
JURISDICTIONAL AREA DESIGNATION REQUESTED:
❑ Water and Sewer ❑ Water Only
LWater Only to Existing Structure(s) 0 Limited Service (Describe in Justification
below)
PROPERTY LOCATION (Address) G °-' K0°II X`4i ,CI 4r'-a'eahn I' '
Tax Map(s)/Parcel Number(s): 5'' /2 f' _ _
CURRENT SERVICE AREA DESIGNATION (If any):
❑ Water and Sewer ❑ Water Only
❑ Water Only to Existing Structures 0 Limited Service
JUSTIFICATION FOR REQUEST: 4 tr2 LA) We/i 'l/ .�
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For Staff Use Only
DATE SUBMITTED: CIS/1`f 1 L T DATE $130 FEE PAID: /`f/`;i —
PROPERTY IS LOCATED (Check Appropriate):
❑ Inside or PrOutside a Growth Area? Adjacent to SAJA?
Inside or ❑Outside a Water-Supply Watershed? 0 Adjacent to a Growth Area?
Location and distance of water/sewer line proposed to provide service 6-DO
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REQUEST FOR AMENDMENT ADOPTED: 0 Yes 0 No Date of Action