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Show STATE OF UTAH DIVISION OF STATE HISTORY '. HISTORIC SITES SURVEY (Type or Print - Complete AppliCable Sections) [1:V/:fJAM(.i/:)·;·:.'\::':·\::iD{i!d/\)\\/:/ii?///)::::::).},\}?·:»:(\:\/:'iii;/Ut).?jU'(::UX.)///~ii;/'/r:\\:\·/)::!~~:.'}j.:.~;/':;\\/:·/>·;:;:i;:~:·::):;)))~::.:j:::::\!i::~;/;:./)\i Common : ~Ila/.:f.qn ~dwol. Ii,," Jr/i.ng ".J ALlfho rhllnrh and/or Historic : '-' City, Town, or Township 41lal.i:mL I Code I County : State I Code I 43 I WaAhi.nt;;.ivn UTAH 1 k~~}(¢.~~~t!.J*AiJPN<}}:C'/':}}}:C\\(;;;::ii:~t\\\/.U::)\~>Y:\\:;'Y/:>\;.\()?~:::::.::)/)}?t:it{\\i:/(:i)?:>//j/{'/<\<::};·;:,'\/::::;/}::::/:.:\':\W{::?\i}~.:: CATEGORY (Check One) District Site 0 0 Object OWNERSHIP Buil<;I.ing · ".~ Public Structure 0 Private 0 ~ Pub"lic Acquisition: 0 0 Both ACCESSIBLE TO THE PUBLIC STATUS 0 Being Considered 0 In Process 0 Occupied ~ Preservation work in progress 0 Unoccupied Yes : Restricted Unrestricted 0 iii) L ~~~~_ _~~~~_ _~~_ _~_ _~~~-4_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ _ _ _~_N_o_: __________ D--1 ~ PRESENT USE (Check One or More as Appropriate) ~ Agricultural Commercial o o o Government Industrial 0 0 Park Private Residence 0 0 Transportation Other (Specify) 0 0 Zoning (Spec ify) Comments 0 o oo c "... 0 Religious 0 Entertainment o Museum 0 Scientific 0 [lW\~\~~lfQf.JfflQp.t.Hr.¥:\\()i:·:.:·/:!})(i()\//(i~!i(;·:{:;·;:··\·;·J/.: '\~·:})\:)\::?:::j:.:~:~i:/?).::::·\j·;\=:::/«:/t~~:::.::.:.::\··::.(·:.:::::;:,\::::·,;-:,::,::·: :· " ;·,{:,',.:;.:'::/:/{Y)// Educational Military < Owners Name: tVMlL:.nt;ion Coutti.y ~----~~~----------------------------------------------------------------------------~ ( Street and Number: en r=~--~--------------------------------------~~~----------------------------~~~~r=~-f~~ ;..~ C ity or TO~: _X L 9-r_ "'./7 ~ IStaUte : Zip cOdell c de 0 ~n KJ,Jf; " ~ 'tTl. 43 T AH Approximate Acreage of Nominated P'roperty : r~C;:i~~R.:ts';;W1A:t(Q:f(ii';'t~X$11.~i(¢.;.$.v....tYE:Y.$}:}!fJ(!~:j!(\///(:(;(:·:·:·\:)/).'?/:\(/'.\:?///~!/\(;';:?·::··});·;::::\>:f)Y)i~:!/)\:;U.:\}{/:::=i::(r='J: ~ ~T_it_le__of_S__ e_y_R_e_C_o_rd_s_:____________________________-=~__~~=-~~______~__~__________~__~__-=~,~ UN __ Date of Survey : Federal 0 State 0 County Local 0 "!' ~~~~~~~~~----------------------------------~---------------------;~ Depository for Survey Records : ~----------------------------------------------------------------------------; ~ Street and Number : I r=C~it-y-O~f~T~o-w--n: --------------------------------------~IS~ta~t~e-:----------------------------~Z~i-p~c~o-d~e-~lc~o-d~e' Form HSS- 1/69/3M 0.. ... ~ co |
