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TOWN OF PLEASANT SPRINGS <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: Aulni o- 14, 201.4 <br /> Name: eye. <br /> Address: 4.1s Sa,./c. r <br /> Address or location of the property where the driveway is to be placed: <br /> L ,f. L- ee.H7 t er5 <br /> ATTACH DRAWING OR MAP SHOWING DRIVEWAY LOCATION <br /> ON ABOVE PROPERTY. (Specify footage from lot lines) <br /> Date approved by Road Supervisor: ., °-- — / ) <br /> Signature of Road Supervisor: /�,�►�,.� _ � �-�� <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 /> ny- <br /> Signature of Applicant <br /> c:/docs/plencomlapplication packet/drivplac.doc rev 08/98 <br />