Land Use Application

                   APPLICATION FOR LAND USE PERMIT

QUINCY TOWNSHIP, FRANKLIN COUNTY, PENNSYLVANIA

7575 Mentzer Gap Road, Waynesboro, PA 17268; telephone 717-762-5679

The undersigned hereby applies for a Land Use Permit to build, erect, remodel, drill a well, add an accessory structure, etc. to a property within the confines of Quincy Township.  The proposed construction will be as detailed below and in accordance with a more detailed drawing attached (approved subdivision/land development or hand-drawn sketch plan).  Upon approval and issuance of this Land Use Permit by the Township, application for a Construction (Building) Permit must be made from an authorized Township Inspection Agency, if required.  Upon completion of the project as described,  applicant must notify the Construction Permit issuing agency who will issue a Land Use and Occupancy Permit for the Township.  The structure may not be occupied or used in any way until issuance of a Land Use and Occupancy Permit.  Also, in certain instances prior approvals may be required from the Department of Environmental Protection, Quincy Sewer Authority, and/or the Township’s Sewage Enforcement Officer approving the method of liquid waste disposal.

PART I (front): TO BE COMPLETED BY APPLICANT; PART II (reverse): BY QUINCY TOWNSHIP

LAND USE PERMIT NO. _____________   Tax Parcel # (assigned by Twp.)________________

1. Name of Landowner:________________________________ Telephone #______________

2. Address of Landowner (City, State, Zip): _________________________________________

3. Builder/Contractor Name:  ____________________________________________________

      Address:    __________________________________________   Telephone: __________

4. Property Address: _____________________________Development Name: ____________

5. Lot type:   Corner _____       Through _____        Interior _____       Cul-de-sac _____

6. Lot size:  Front width ______   Rear Width_____ Left depth _____   Right depth _______

7. Signs:  Any signs to be erected on lot, if so, describe: _______________________________

8. Brief description of proposed work:  _____________________________________________

      __________________________________________________________________________

9. Size of proposed structure: _________________________  Height (ft.) or stories _________

10.  Cost of Construction upon completion or value of structure purchased:    $_______________

11.  Building Use:   Commercial ____ Residential ____ Farm Use ____ Other ____

12.  If mobile home, answer following:  Titleholder’s name and address _____________________

      __________________________________________________________________________

   Value of unit:  $__________    Make  ___________    Year  ______       Size__________

13.  Basement:      Full ____ ¾ ____ ½ ____     Crawl space ________ Slab ______

14.  Finished Basement:   Yes ____    No ____   Partial ____

15.  Number of rooms in dwelling: Bedrooms ______ Bathrooms_______ Living Rooms_______

   Family Rooms ______ Dining Rooms ______ Kitchen ______ Den ______ Other ______    

16.  Exterior walls/roof materials___________________________________________________

17.  Central air conditioning: Yes _____   No _____   17a.  Number of fireplaces:  ______

18.  Kind of heat: Forced hot air ____ Steam _____   Electric radiant (ceiling) _______

   Electric Baseboard ____ Hot water Baseboard ____    Heat Pump ____ Other ______

19.  Water System:   Public ____      Well ____ Cistern ____ Other ____________________

20.  Sewage System: Public ____   On-lot ____ Percolation Tests Done: Yes____  No _____

21.  Other pertinent details:_______________________________________________________

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Applicant must attach Lot Plan drawing showing the location of current and proposed structures as well as setback distances between those structures and adjoining property boundary lines. Applicant must also obtain a Construction Permit if the appropriate box listed below is checked “Yes”.   If checked no, this Land Use Permit will serve as the construction permit and will be displayed on the premises as such during construction.  Applicant must notify the Township for site inspection when structure is laid out prior to beginning any construction.

Applicant is:   Owner ____ Contractor ____ Agent ____ Other (describe) ______________

Name of Applicant:  ___________________ Bldg / Demo Permit Required: Yes_____No_____                                                                                           (print)            

Signature of Applicant: ________________________Date of Application: ___________________

REQUIRED BUILDING YARD SETBACKS FOR THIS LOT ARE: Front _____ ft.   Rear____ft.

Applicable Zoning District:  _______________                                    Sides_____ ft.

Pre-existing Small Lot Setback Provisions Apply: Yes____ No ____

Private well setbacks: 10’from property lines & street rights of way.

100’from septic fields; 50’from septic tanks; & 10’ from public sewer laterals. Public well setbacks: 100’ from septic tanks or public sewers.   

PART II:   TO BE COMPLETED BY QUINCY TOWNSHIP

LAND USE PERMIT CHECKLIST

Where checked “yes”, the proposed project will require adherence to selective provisions in Township Ordinances or other written requirements:

YES

NO

N/A

DATE

1. Subdivision/Land Development Ordinance

        (SALDO)

2.   Zoning Ordinance (see setbacks listed on

       front side.)

3.   Stormwater Management Ordinance (see

  drywell or detention basin models attached.)

4. Junkyard Ordinance

5. Septic System/Holding Tank

6. Public Sewer, QSA

7. Well Construction Ordinance (see setbacks

        listed on front side.)

8.   Public or Central Water (see attached  

      excerpt from SALDO.)

9. Township Roadway Occupancy Permit

      Requirement (see attached form.)

10.  Pennsylvania Roadway Occupancy Permit

      Requirement

11.  Floodplain Ordinance (see attached

      excerpt from Zoning Ordinance.)

12.  Mobile Home Park Ordinance (see

       attached except from Zoning Ordinance.)

This Land Use Permit application has been reviewed for adherence to applicable Township codes and ordinances and is administratively approved by the undersigned for submission to the Zoning Officer for issuance of the official Land Use Permit:

 

                    ________________________________ (Township Programs Coordinator)

Based upon the applicant’s certification shown on the front side of this permit, and the implied assurance that all items checked YES above will be addressed by the landowner as construction proceeds, I hereby approve and issue Land Use Permit #______________

                                ACCREDITED SERVICES, INC. (CODE ENFORCEMENT OFFICER)

                                           

        SIGNATURE OF CEO:________________________   DATE: _________________

All items checked YES above have been satisfactorily completed and Land Use Occupancy is approved for this Land Use Permit.

                                           

TOWNSHIP UCC INSPECTION AGENCY ________________________________

       SIGNATURE OF APPROVING OFFICIAL:________________________________

THIS PERMIT IS VALID FOR 18 MONTHS.  WORK SHALL START WITHIN 9 MONTHS OF ISSUE.

Fees:

         Land Use  $______________                     Site Inspection Date         ___________

         Driveway       $______________                 Driveway Inspection Date  ___________

         Road Impact $______________          Setbacks Inspection Date ___________

         Other          $______________                        Front    ____            Rear   ______

             Total Fees ______________            Left Side ____      Right Side  ______

                                                                                Driveway    Stone ____   Paved ____

PERMIT EFFECTIVE DATE _______________        Quincy Township Supervisors

                                                                                        7575 Mentzer Gap Rd, Waynesboro, PA 17268


PERMIT EXPIRATION DATE ______________         717-762-5679