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HomeMy WebLinkAbout15-04 Ritenour Property - Restaurant - Services - Opequon - Backfile (2)' 003747 � O Date + I �c Received From Z— / �- w W i Address77 ww_a�' ! C�" C £ o>� Dollars$ W ��U 8 For t.. A S / — j.I! o In OE7z= U Z n U Z o z ACCOUNT HOW• U Z EE Aw OF ACCOUNT IA ;. wa w AMT PAID SITE PLAN TRACKING SHEET Date: —H4Z0 File opened Ith—V Reference Manual updated/number assigned -14 Lo- D-base updated Dh' File given to Renee' to update Application Action Summary —Pat_ CLOSE OUT FILE: , �/ 0 - Approval (or denial) letter mailed to applicant/copy made for file File stamped "approved", "denied" or "withdrawn" ��� o� Reference Manual updated qd. & D-base updated �j 3 • D File given to Renee' for final update to Application Action Summary U-\Carol\Common\Tracking shecu\Sitc Plan Tracking wpd Revised 02/07/03 SITE PLAN APPLICATION CHECKLIST The checklist shown below specifies the information which is required to be submitted as part of the site plan application. The Department of Planning & Development will review the application to ensure that it is complete prior to accepting it. If any portion of the application is not complete, it will be returned to the applicant(s). (1) One (1) set of approved comment sheets are required from each relevant review agency prior to final approval of a site plan. It is recommended that applicants contact the Department of Planning & Development to determine which review agencies are relevant to their site plan application. A list of potentially relevant review agencies is shown below: y Frederick County Department of Planning & Development Department of GIS (Geographic Information Services) Frederick County Sanitation Authority _Frederick County Building Inspections Department County Department of Public Works \/Frederick Frederick County Fire Marshal L--" Frederick County Health Department T---. Frederick County Department of Parks & Recreation Virginia Department of Transportation (VDOT) City of Winchester �— Town of Stephens City Town of Middletown Frederick County / Winchester Airport Authority (2) One (1) copy of the Site Plan application form. (3) Payment of the site plan review fee. (4) One (1) reproducible copy of the Site Plan (if required). FREDERICK COUNTY DEPARTMENT OF PLANNING & DEVELOPMENT Site Inspection Form GENERAL INFORMATION Permit Holder flame Property Identification 27umber (Pill) --a ----- - Site Plan or Subdivision Plan Number Location {' ^ 9uilding permit Number Contact- Information INSPECTION OF ROADS, DRIVEWAYS & TRAVEL AISLES (Check when completed - note all incomplete work)s Street & Traffic Signs Striping Surface Material Comments_ Sidewalks & Lighting Dimensions Overall Layout Inspector Date Verified Incomplete Inspector Date Verified Complete INSPECTION OF PARKING, MANEUVERING AREAS Q LOADING AREAS (Check when completed - note all incomplete works Number of Spaces ____ Striping —� Surface Material Comments Sidewalks & Lighting Dimension of Spaces overall Layout / Date Verified Incomplete Inspector i Date Verified Complete Inspector O-J"- o�- INSPECTION OF LANDSCAPING IMPROvtN NTS (Check when completed - note all incomplete work)s Number of Trees V Number of Shrubs Plants Species of Size of Plante T✓i Seeding Soil Stabilization �— Overall Layout Screens Comments Inspector s Date Verified Incomplete Inspector �d j Date Verified Complete INSPECTION OF OTHER IMPROVEMMMS (Check when completed - note all incomplete work)s Setbacks Recreational Facilities Proffered Conditions n/ Preservation Areas � Curb 6 Gutter Signs Comment Inspector - Inspector -- Date Verified Incomplete Date Verified Complete FAZDERICK COUNTY DEPARTMENT OF PLMN114G St D: %ELOPMENT - FINAL SITE APPROVAL Date o Appr val Signa ure is site approval contingent on a monetary guarantee? Yes* _ No ✓ Bond Number (-If yes, all site improvements noted on this form must be complete prior to the release of a monetary - guarantee. In addition, all relevant review agencies shall provide final site approval. A checklist: of these agencies is provided below for documentation purposes.) Fire Marshal Virginia Department of Transportation _.. Sanitation Authority Building Inspections _ City of Winchester - Public Works parks & Recreation — Other (Please dare & initial when all site work is ccmplete & all relevant review agencies have approved) Initials Date Monetary Guarantee Released _ COUNTY of FREDERICK Department of Planning and Development 540/665-5651 FAX: 540/665-6395 M April 29, 2004 - FILE COPY Mr. Darren S. Foltz, L.S. Foltz Land Surveying P.O. Box 23 Stephens City, Virginia 22655 Re: Approval of Site Plan #15-04, Ritenour Property, Route 277 Property Identification Number (PIN) 86-A-14A Dear Darren: The Frederick County Department of Planning and Development administratively approved the above -referenced site plan on Apri129, 2004. The site plan is approved for the re -use of the existing building at the above -referenced property (former bread store). The site plan is approved for a 2,400 square foot restaurant and 3,049 square feet for personal services or general offices, as permitted in the B 1 Zoning District. Parking lot improvements, landscaping, handicap accessibility, lighting, and screening are required for this development as shown on the approved site plan. All requirements for development within the B1 Zoning District have been met. Furthermore, all relevant review agencies have approved the project at this time. I am providing you with several copies of the approved site plan. Please forward these copies to the appropriate representative(s). Furthermore, advise the owner(s) that a copy should be kept for future reference, and an approved copy must be kept on the construction site throughout the development process. Once site development is complete, the owner(s) should contact this office to schedule an on -site inspection. Do not hesitate to contact me should you have any questions or concerns. Sincerely, Jeremy F. Camp - Planner II JFC/bad Attachments cc: /Bill Ewing, Opequon District Supervisor /Jane Anderson, Real Estate Ben Ritenour (owner) Patrick Barker, Economic Development Commission em: Roger Thomas, Opequon District Planning Commissioner /Rick Ours, Opequon District Planning Commissioner. 107 North Kent Street • Winchester, Virginia 22601-5000 t -r o u Request For Site Plan Comments Frederick County Inspections Department A- . RECEIVED Mail to: Frederick County Inspections Dvpt. Attn: Building Official 107 North Kent Street Winchester, VA 22601 (540) 665-5650 Hand deliver to: F11 0 G 2004 107 N. Kent Street Fourth Floor t7RaiTucoul iv Winchester, VA=CdY0R.1AIySIECTIW;1 (540) 665-5650 Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach one (1) copy of the site plan with this sheet. Applicant's Name: Fv L��-Z SUZVE_y ) t'j Address'. Q o 66y, 2 S t 1= i> N-E r j S C 1 1 \I V Phone Number: �� J 2� ^ ) L� c 9 Name of development and/or description of the request: 2 Is I �j G l—UT 1 rn vv Em E,JT L{k (� i 7 r`► D U (Z -+PR d PEST -TC 2-1 rl Location of property: Inspections Department's Comments: C(-,,)rn n, n 1—,IREolY i kL �3' C� `� r''?je}iYsr }C xi'-� �..Lr. •'�4 {t S t �F�<��. � -'��`-^�': i. :t Inspections' DeptS;useYonly t.1'`5 t tqE ti t tilt 'd-1�e i--tt ?� (�'�°. r r Date a loved t PP Date receivedreceived t t •t'�.""qq>} r�y}Aw�yp2 to?;;���'���'°1sl A3.} �:•�, �. -ja'. t a futc ` lets ar W", w\-l�''', ct ,1 a r'rt tIncomplete h'�t� _ �3 , .- - -30 ,��.e +"r i7•. :. i � ( . _C'A�^t� _� a+x .aJ...Faav: s a�� Slf fP.VI Ed Ani -Rem". Signature°and Dater 4 H,i SigraturetandD'ate (revision - 16 HC parking space's shall comply with the CABO A 1 17.1-98 Accessible and Usable Buildings and facilities. Please note the requirements for Van Accessible Sign. The accessible route from the parking to the building entrances is not shown at this time. • • 3'- Control number S PO4-0005 Project Name Ritenour Parking Lot Address P.O.Box 23 Type Application Site Plan Current Zoning 61 Automatic Sprinkler System No Other recommendation Emergency Vehicle Access Adequate Siamese Location Not Identified Emergency Vehicle Access Comments Access Comments Frederick County Fire and Rescue Department Office of the Fire Mars.hal__ Plan Review and Comments Date received 2/6/2004 City Stephens City Tax ID Number 86-A-14A Date reviewed 2/9/2004 Applicant Foltz Land Surveying State Zip VA 22655 Fire District 11 Recommendations Automatic Fire Alarm System No Requirements Hydrant Location Not Identified Roadway/Aisleway Width Adequate Date Revised Applicant Phone 540-323-1497 Rescue District 11 Election District Opequon Residential Sprinkler System No Fire Lane Required Yes Special Hazards No Additional Comments Fire Lane No Parking signs and markings required along the access road to the rear of the building and parking per Frederick County Code section 90-4 Plan Approval Recommended Reviewed By Signature • Yes Timothy L. Welsh Title �. }�; _. max. • 0 Request For Site Plan Comments Frederick County Engineering Department Mail to: Hand a fiver o. Frederick County Engineering Dept. 107 N. Kent Street Attn: Director of Engineering Fourth Floor 107 North Kent Street Winchester, VA Winchester, VA 22601 (540) 665-5643 (540) 665-5643 RECEIVED FEtA () l; 2OOh JRUVRICKCOUH11 rdBLICWQRJl & it',inEnoP. i Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach two (2) copies of the site plan with this sheet. Applicant's Name: Fv �( Z >—I�N >> ju ZyE\-j I Address: C5- —k-e,P► Phone Number: Name of development and/or description of the request: vcmI-N I PL-R Engineering Department's Comments: Engineering Dept ,use}on]yJ 76 - cAl U �Ce r � q,` Y� �. .�r ♦f � t i,ka C'�`Sii I .f. r � - � v- {�^�� tY j r-> > ^s� f ,� Date received +'��(+k77 .Date revision ieceived�'� J `, 4�sDate{apro�ved tl1�f,,<�^=L"G I,F +1+i Y1' MYttfiir � .:`` 1.. Th'}'S•T� �� ;Incomplete Incomplete �" i1 Date reviewedz'Z Si ature and Date ,,r5.,ri.T= L"-�'.;% Signature and Date. (revtision 17 FLSA Request For Site Plan Comments p i1 Frederick County Sanitation Authority I LW4U_TT-911-r1-f Uzi Mail to: Hand deliver to: Frederick County Sanitation Authority 315 Tasker Road Attn: Engineer Director Stephens City, VA P.O. Box 1877 (540) 868-1061 Winchester, VA 22604 (540) 868-1061 Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach two (2) copies of the site plan with this sheet. Applicant's Name: �U t, 2 U-Z\jEy f tJC Address: S_rC: P1-1 Crj S C1-T q V1i GZiL�SS Phone Number: 540 W­f rl Name of development and/or description of the request: m -2(2 -o yr mE �,J Location of property: �� t (; T� ci-I Ef,3 S Frederick County Sanitation Authority's Comments: Q 14 C`ln�ioI Oo,-I3 D� Request For Site Plan Comments Frederick County -Winchester Health Department Mail to: Frederick -Winchester Health Department Attn: Sanitation Engineer 107 North Kent Street, Suite 201 Winchester, VA 22601 (540) 722-3480 Hand deliver to: 107 North Kent Street, Suite 201. Winchester, VA (540) 722-3480 Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach one (1) copy of the site plan with this sheet. Applicant's Name: FrOLT z— Ul�i Address: Phone Number 540 _ 3Z3® 14177 Name of development and/or description of the request: P^A-iL, u &— Lo r- I K IA"V% M F N T Location of property: 3 41 P A I R F ArX F1 KID. Tip! 1-t�t�J G. Health Dept's Comments : A restaurant permit must be obtained from the health department prior to operation of the restaurant An application for the permit and one set of plans must be submitted and approved in order to obtain the permit. The health department has no objection otherwise as long as public water and sewer are provided. •i, z y.Je.r}..�4hy'y r'"� It. sw "' aft^ d r r » � i a g ri5t a a r. '. Health Dept use nit�r`= Ii ,t bo1� yA�'j�i rrai�r�. r 'i •i "'�i }. t } �r�l t` t + ;�a r t 3� 1 3 lYr'f tyf �r .tit yTi �ji? Date,received,=�r r ��Cp" Date revisioareµc-eived t i Rai, Date approved+- '!� ={♦ ttSr-.o�'ct t y,Vyt�'tW i ��f.iN'l $f��},jfb'T l.�?'✓ 51a. }, �t�s..t r�i-; .� ; , JY- t }sat t 'z 3`7�s c i f6 R rIDCOm lete tm s gar L c r� t i r 1 Incomplete,�� des P f. , , T i z; , �f-:td ''i L4S+T1 ^•>:ti'vh -ff "'� � „ydare �ds4>.fff `f•ri 3 d�tti '•ns�c' iJry,�a r t DatereyieweLYerev�ewe Signature Signature.and Date,(revision) 20 Mail to: Virginia Department of Transportation Attn: Resident Engineer 14031 Old Valley Pike Edinburg, Virginia 22824 (540) 984-5600 Request for Site Plan Comments? Virginia -Department -of Transportation. p Hand deliver to: Virginia Department of Transportatid 2275 Northwestern Pike Winchester, Virginia 22603 (540) 535-1818 Please fill out the information as accurately as possible in order to assist the Virginia Department of Transportation with their review. Please attach five (5) copies of the site plan with'traffic generation data and drainage calculations with this sheet. Applicant's Name Address: C_() LfZ I.._AN_ 2VE-- i t J 00 1 S (,'-.t i -I \r>L Z Z (o `> J Phone Number: 3ZZ) _ 1 491 Name of development and/or description of the request: Q C Lo i 1`1ouz. Location of property: 4 1 �� 1 �PA,�L Virginia Department of Transportation's Comments: The application for site plan for this h•"p-'j appears -to have little mead,raF e-i+ pac-�Wte 277, the VDOT facility which would provide access to the property, As the planned widening of Route 227 is several years away, the existing entrance will need to be brought up to current standards including the a ion o - versus paining will e required. - • • • use perMit will need to p`piiecl forand (;supLl to cover rairi work The permi�-�ed-"is-effiee-and--reqt�reg-a-fee-and-surety-bu,id coverage. 13 • COUNTY of FREDERICK Department of Planning and Development 540/665-5651 FAX: 540/ 665-6395 March 24, 2004 Mr. Darren S. Foltz, L.S. Foltz Land Surveying P.O. Box 23 Stephens City, Virginia 22655 Re: Review Comments for Site Plan #15-04, Ritenour Property Property Identification Number (PIN) 86-A-14A Dear Darren: Staff has reviewed the above -referenced site plan, submitted on March 1, 2004. At this time, the site plan is denied until the comments listed in this letter are adequately addressed. My review comments are as shown below: Review Comments: 1) Tax ID #. Please provide the Tax ID #, also referred to as PIN, on the site plan. 2) Current Use. Please change the reference that the current use is vacant and replace it with the more accurate reference that the current use is an abandoned retail building. 3) Existing Gravel & Zoning Buffer. Please remove the existing gravel in the zoning buffer and provide topsoil and grass seed. Please show and label this on the site plan. 4) Signs. Please provide the details of the proposed sign. Please also ensure that all signs are a minimum of ten feet from property lines. This does not appear to be the case with the sign shown at the entrance on the proposed site plan. Please change as necessary and provide a statement on the site plan to the effect that all signs shall be required to obtain a sign permit through the Department of Building Inspections prior to installation. 5) Lighting. Please show all proposed freestanding and wall mounted lighting. If lighting is proposed on the site, please provide a statement on the site plan to the effect that all lighting shall be shielded and/or directed away from adjoining roads and properties to prevent light pollution. 6) Entrance Islands. Please clarify if the entrance islands will be landscaped (grass) or if the area will be paved. 107 North Kent Street • Winchester, Virginia 22601-5000 r • i Page 2 Mr. Darren Foltz Re: Review Comments for S.P. 415-04 March 24, 2004 7) Landscaping. Please provide a list of all required and proposed landscaping. This would include the trees within the zoning district buffer, the evergreen hedge rows, and any other proposed landscaping. The species, quantity, caliper of deciduous trees, container size of slu-ubs, and height of evergreen trees need to be provided to ensure compliance with the County's landscaping ordinance, Section 165-36. 8) Revision Dates. Please show all revision dates on future revisions of the site plan. 9) Signature. Please provide your signature on the Land Surveyor Seal for all final sets of plans. Once you have adequately addressed all of these comments, please resubmit a copy for my review. I will need all approved review agency comment sheets and at least five copies of the final plans for approval. Comment sheets are required from the following agencies: The Frederick County Department of Building Inspections, The Frederick County Fire Marshal, The Frederick County Engineer, The Frederick County Sanitation Authority, and the Virginia Department of Transportation. Feel free to contact me with any questions or concerns. Sincerely, Jeremy F. Camp Platuier II JFC/bad cc: ✓ Ben Ritenour (owner) SITE PLAN APPLICATION Department of Planning and Development Use only. Date application received: / rl Application # Fees received:) Initials: --� 1 Project Title: ?, 1 T0-NJJ/Z 1 rLp �p�iL•'�,f R 2-17 2. Location of Property (street address) s'frc f�l-4t'�-IS CA TN u Ar- 2-7- 3. Property Owner: Address: Z-0 F-A.c f- ¢ 7 l-10JT14 L.AJ. S rti--P►-,eN s Telephone: ryo — S loci _ O (0 rip 4. Applicant/Agent F-6L'n� u1..No �";J'WM4 1 X)L— Address '1. 0, 5oy, 23 5TW►+=t,.►5 C1 2Z S $— Telephone: .S �'d 3 Z3 '� e` 4 l 7 5. Designer: Address: Telephone: Contact: 6 le.1::'yrx 6a. Is this a standard or 'minor' site plan? Standard Minor 6b. Is this an original or revised site plan? Original %o�ff J Revised 7a. Total acreage of parcel to be developed: 30, 637 7- Is Q F--I- 7b. Total acreage of parcel: •300 137 Q PT 8. Property Information:A- a) Property Identification Number: 1 ta' "� /'� 1 4 #' b) Current Zoning: c) Present Use: d) Proposed Use:�`fAV�f4�l`T e) Adjoining Property Use(s) 56E l3CLoyJ f) Adjoining Property Identification Number(s) 5 C r-- aF-Lov./ g) Magisterial District(s) ®?!F'o,-Q C)t.,] I have read the material included in this package and understand what is required by the Frederick County Planning Department. I also understand that all required material will be complete prior to the submission of my site plan. Signature: ' Date: f z-1, 8l6® At-I2�? 8(pD- 14 -1BA 01-)5-7 0 6-PNC E 0— Special Limited Power of Attorney ('ounfy of Frederick, Virginia Planning Office, County of Frederick, Virginia, 107 North Kent Street, Winchester, Virginia 22601 Phone 540-665-5651 Facsimile 540-665-6395 Know All Men By 'Iliese Presents: 'Iliat I (%Ve) (Name) �Gtv r�� 0 — (Phone) 9c,9-5—L-r--0 (Address) 3+1 F/'t t %-►�A X IJ2 Sf c,�c�►-�S C � nl �A ZZ�SS the owner(s) of all those tracts or parcels of land ("Property") conveyed to me (us), by deed recorded in the Clerk's Office of the Circuit Court of the County of Frederick, Virginia, by instrument No. 0 Z 00 ► S 1 17 11. Page and is described as Parcel: 4- do hereby make, constitute and appoint: (Name) l (Z2.�=4-J �-p U TZ-- &:a ak)— 14Ar (Phone) 5�4 O 3 l 47 (Address) 123 To act as my true and lawful attomey-in-fact for and in my (our) name, place and stead with full power and authority I (we) would have if acting personally to file planning applications for my (our) above described Property, including: ❑ Rezoning (Including proffers) ❑ Conditional Use Permits ❑ Master Development Plan (Preliminary and Final) ❑ Subdivision Site Plan My attorney -in -fact shall have the authority to offer proffered conditions and to make amendments to previously approved proffered conditions except as follows: This authorization shall expire one year from day it is signed, or until it is otherwise rescinded or modified. In witness thereof, I (we) have hereto setur)hand and seal this day of ��i!�CL2.200 , Signature(s) . Vv �/J(� - C I , To -wit: State of Virginia, City/ i of f'UI 1, �I Y-IA LGa/(�h04tary Public in and for the jurisdiction aforesaid, certify that the persor.(s) who signed to the foregoing instrument and who is (are) knovni to me, personally appeared'•)efore me and has cknowledged the same bef e me in the jurisdiction aforesaid this S' day of My Commission Expires: Notary Public • Request For Site Plan Comments Department of Planning and Development Mail to: Department of Planning and Development Attn: County Planner 107 North Kent Street Winchester, VA 22601 (540) 665-5651 Hand deliver to: 107 N. Kent Street Fourth Floor Winchester, VA (540) 665-5651 Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach two (2) copies of the site plan with this sheet. Applicant's Name: Address: C) Z 3 Phone Number: -5--O — 3Z-3 — 14q Nag��, 7of development and/or description of the request: -\ PrfL1L� N ls- :rC�'j Z f� pfl.Oy\c�M t�l T Plrh�l 2T-C z-1 1 Location of property: Z->`i 1 A t fLFix P, k--c > ti s C-- I TIA Vl4 - x 5 S— Planning and Development's Comments: Planning and Development use only Date received Date revision received Date approved Incomplete s. Incomplete k = ; Date reviewed :.- Date reviewed", Signature and Date Signature and Date (revision) 15 • • Request For -Site Plan_Comments Frederick County_ sanitation_A-uthority Mail to: Hand deliver to: Frederick County Sa on Authority 315 Tasker Road Attn: Engineer Director Stephens City, VA P.O. Box 1877 (540) 868-1061 Winchester, VA 22604 (540) 868-1061 �(1 Ll"lA\ p �1�m1111��iIl1U Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach two (2) copies of the site plan with this sheet. Applicant's Name: ��' 1- L- Address: 'f 1 LP L/\r__A7 >Lk2\4L^i<, z Phone Number: 540 _? L � I 11 1-f V(A Z_ 1 0—) Name of development and/or description of the request: P f� �LK I ►,� C, I— C`• Z 1 n) 4 �c- p Y L m Lt\i T 'L- R t2i-T Location of property: 2 4 1 f--I\ t I j tL f'I-► i_ti S Frederick County Sanitation Authority's Comments: Cl I&—t:- .L 1 6, .`_-) Sanitation Authority, use only. Date received Date revision received�A►_ , Date approved 7�t.4jv�.'f, ��. Tip vt� ♦ .t Incomplete:, ><` y+,. ,,�a� . .�r,. ,�• �-�;, �`.t�L� � , Date reviewed Signature and Date,"' Signature and Date (re 14 cl��iC� I CC�' 13 uu Request For Site Plan Comments Frederick County -Winchester Health Department Mail to: Hand deliver to: Frederick -Winchester Health Department 107 North Kent Street, Suite 201 Attn: Sanitation Engineer Winchester, VA 107 North Kent Street, Suite 201 (540) 722-3480 Winchester, VA 22601 (540) 722-3480 Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach one (1) copy of the site plan with this sheet. Applicant's Name. �mj-7. Lit.► 5 U�! Address: T' 0. gDx L3 S 7� 2_►-1 e-VJ S L% Ty AV Z Z G_52_ Phone Number: 540 ^ 3 Z 3 1 411 Najmg of development and/or description of the request: rArd-IL, u &-- Lo T I K p ILO VW-M F W T %-A f Location of property: 3 4 1 P A I R F AX Pj KL'I_r TLp lr� S C_ I T4 --- Health Dept's Comments : A restaurant permit must be obtained from the health department prior to operation of the restaurant An application for the permit and one set of plans must be submitted and approved in order to obtain the permit. The health department has no objection otherwise as long as public water and sewer are t)rovided. Health Dept..'use only 2 i 4• Date received `� " ' :Date revision, received.- Date approved lncomplete %Incomplete, " Date reviewed r . : D e review - Signature and Date ° Signature and Date (revision) -- 20 I • • Request For Site Plan Comments Frederick County Engineering Department Mail to: Frederick County Engineering Dept. Attn: Director of Engineering 107 North Kent Street Winchester, VA 22601 (540) 665-5643 Hand deliver to: 107 N. Kent Street Fourth Floor Winchester, VA (540) 665-5643 RECEIVED I:F1; O i,) MWI flOOMAGOON" WVMWc� &1 - Please fill out the information as accurately as possible in order to assist the agency with their review. Please attach two (2) copies of the site plan with this sheet. Applicant's Name: Address: Phone Number: FO L- ( z L ivj 5 Lk(`V,�_`i ► f\� o (';)U X z -�:) C)I t t-_NA `---> C. \ T ZCr /10 _2_ - 1 _/41,19 Name of development and/or description of the request: f2Av ,,,1 rJ C L O-T n) > \1 L E ►.iT tL' (A I—, E�_j (-) UtZ j I. "(=iL l \1 � i Z rl �-I Engineering Dept. use only.: Date received ar '�er e revision received; >? r, , ,,Date approved Incomplete f ';Incomplete. , Date reviewed ate review�e,d r - Signature and Date Signature and Date (revision 17