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Application 122123
subd.doc 5 01/18/23 VARIANCE/WAIVER REQUEST FORM Plat Name 22VA i.a� I'-t` Owner:_C��- L gL- Address: 1"�. Phone: Date Filed c.' T u File No. Engineer: I -cA- v.-t- � Address:���� Phone: Variance(s) Requested: (l?__ (3 ) Justification: Owner's Signature: Dale -2� SZ- PLANNING COMMISSION ACTION: BOARD OF DIRECTORS ACTION: Approval ( ) Date Denial () Date Basis for Decision: Approval( ) Date -- Denial ( ) Date Basis for Decision: PLAINTIFF'S �� EXHIBIT