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LOt. BlocK: Subdivision: No. AcreS: ~ "-'* <br /> <br /> · I ......... ~.e~G:~,l~ ............. i.............~-,-,,.,,: ........................ ~t ................ ;.......;........1. <br /> <br />· ?..~ ................. -...-.-,......:......-, · t..-.i ......... ...~-~-!+..-....:..-.-.-.-'~......--i <br />.!........~ ................ ;,,.,,.,.] ....... ~ .: ~[ '. <br /> <br /> ,,.?,-,4........~........ ' ' ................................ i ......... i .......................... i-..-,.i.........~ ........ <br /> <br /> I C¢~f7 ~hat [he above infor~,a~on iS accuya~_ )0. th~ best.of my knowledge. ' <br /> <br /> Applicant's Signature: Date: , ,"~7 <br /> FOR OFFICE USE-ONLY <br /> PLANNING: DaU::: <br /> PUBLIC WORKS: Dam: <br />MC: 15-60 BIJE~ING iNSPECTION: Date: ./ <br /> <br /> <br />