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TOWN OF PLEASANT SPRINGS <br /> - . .f- , DRZVEWAXPLACEMENfi FORM 3` _ _ <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: -1c1-4c <br /> Name: Ru 641 a.)tl rj et)^e t Vee k <br /> Address: 1,T.5" 1/eek jet <br /> SfJA ri <br /> Address or location of the property where the driveway is to be placed: <br /> CCU .� cic(655 freyri 9C/E 7&et I)," . <br /> LJ�°s T <br /> 5'16.1c- o f ices // "A'M' " , 7h1 '/G�l'4e i to y f)07- <br /> 7 1% e t'.e( Itr1G( ,Sh 4/ he Aire_ t G /(/ z,/ 4'1\1664/l y is <br /> 1e t ' ved 3s Pr tr e f t1a NE At Lei . .71-t c✓,li <br /> C evit-r- '{-- TA& CW e t„rt y <br /> ATTACHA DRAWING OR MAP SHOWING DRIVEWAY LOCATION <br /> ON ABOVE PROPERTY. (Specify footage from lot lines) <br /> Date approved by Road Supervisor: Q �� / /S 2 <br /> Signature of Road Supervisor: CG'z)i <br /> Date approved by Plan Commission: ( ((=; <br /> Signature of Plan Commission Chairperson: 14- <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 /> (L1 c <br /> Signature of Apple:nt <br /> c:/docs/plancom/application packet/drivplac.doc rev 08/98 <br />