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Zone: Map: <br />S~: ~ ~ T ~ Range: <br /> <br /> Lot' Block Subdivision: No. AcreS: <br /> <br /> .................. &.-...-'~ ................. i "'""i"'"""l""'"? "'"'"? ""'? ................. ~ ................ : <br /> <br /> I certify that the above information is accurate to the best of my knowledge. <br /> Applieant (Please Print) b4,z~_ p~.,, /'x-~>~t~ Phone; <br /> <br /> Applicant's Signature: Date: <br /> FOR OFFICE USE ONLY <br /> PLANNING: Da~e: <br /> PUBLIC wORKS: Date: <br /> BUILDING INSPECTION: Date: <br />MC: 15-60 <br /> <br /> <br />