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SCALE DRAWING OR MAP of the parcel must be included with this form. Include as <br /> much detail as possible. All current or proposed structures, sewage systems and roads <br /> must be shown. A crude sketch will not be accepted. <br /> ADDRESSES OF NEIGHBORING LAND OWNERS list of names,addresses and <br /> phone numbers of surrounding landowners. <br /> If professional services are required of the Town of Black Earth Engineer or Attorney <br /> these cost are passed on the applicant. <br /> I HEREBY CERTIFY that the information provided on this notice is true and correct. <br /> Signature 644. <br /> Print Name C k f A s tleucno0A A <br /> Date (4 <br /> Town Clerk y n,A tit. �zE IS <br /> Date Received 11-1342-o, Fee Paid Z5° •° <br /> Avopov Co/7 /Z o/C <br /> NOTED: This application is valid for one year. <br /> 2 <br />