DEARBORN COUNTY APPLICATION

Location Improvement Permit Application

APPLICANT

Name:

Daytime Phone: --
Address:

City:

State:

Zip Code:

OWNER OF PROPERTY

Same as Applicant

Name:

Daytime Phone: --
Address:

City:

State:

Zip Code:

SITE LOCATION

Township:

Subdivision:

Lot #:
Location:

Acreage:
Section:

Township:

Range:

Map #: -

Parcel #

SITE INFORMATION


Existing Use (Check One) Vacant Land Single Family Residence Manufactured Home Mobile Home Other:		Proposed Improvement (Check all that apply) Single Family Residence Manufactured Home Mobile Home Addition Pole Barn / Shed Attached Garage Detached Garage Porch / Deck Swimming Pool Other:
Sewage System (Check One) Public Sewer Septic Tank N/A	Structure Height (Check One) 1 Story 2 Story Bi-Level Tri-Level A-Frame 1 1/2 Story
Water System (Check One) Public Water Well Cistern N/A