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TOWN OF PLEASANT SPRINGS <br /> r _,,, , ., ,, DRIVEWAY- PLACEMENT FORA : <br /> This form must be completed, signed by the Road Supervisor and submitted <br /> to the Clerk/Treasurer prior to approval of your Preliminary Certified Survey <br /> Map. <br /> Date: 6r1-: /Of Ze/5 <br /> Name: <br /> Address: 2. /4' AP <br /> .S // 9/ Ai j Al , 56 7 <br /> Address or location of the property where the driveway is to be placed: <br /> OF 1N a 3/e9 fr,7 9) 7- <br /> N 14 N 7214' ve <br /> A T.TA CH A DRAWING OR MAP SHOWING DRIVEWAY LOCATION <br /> ON ABOVE PROPERTY. (Specify footage from lot lines) <br /> Date approved by Road Supervisor: .5, :/-2-. /6_,/_____/9-- ._.._ <br /> Signature of Road Supervisor: Wdiyc4 <br /> Date approved by Plan Commission: <br /> Signature of Plan Commission Chairperson: <br /> I understand that the approved driveway placement on the attached map, as <br /> approved by the Town of Pleasant Springs Road Supervisor and Plan <br /> Commission, cannot be altered in any way. The driveway placement must be <br /> shown on the Certified Survey Map. <br /> 1 <br /> • - 4. ' a i <br /> _. �� <br /> Sig 4 re of Applicant <br /> cidocs/plancom/application packeUdrivplac.doc rev 08/98 <br />