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•... ' Pw iai2 -oa� <br /> Washington Slate <br /> �� Gepartrnentofhansportation Application forGeneral Permit <br /> Permit No. GP OG 1412 <br /> � Ip icant• Plr�aseprint or type all information ____ _ __ _ ____ _ <br /> App'�wPon is He:eby Ilade For. � General Perm�1 (No Fee) <br /> ❑ General Perm�,t 52.50(Subjed to RCW 47.12.1a0(2)) Reimb.Accl. <br /> Intended Use of State Right of W�y u b Cons;ruct,Operate,and Maintain a: <br /> "I�n m�fy;n.vr.�etation and irstall A" minis quur;�snallc wi�hin YJSI1�Tr�ghL.nf_wa}'-(t�chinilsoun�_v'al I ;m�t <br /> adjoinin�vn_mpe2y��o.pce�eutrrosiniLtiomdrain"�;�pe.Sects!tihiL"A"forSlirilicr.dcLvlsand_restriciinns. . —. <br /> on a porlion o1 State Roule 5 (aUfrom)Id]ePost 19I.44-L to Mile Post _ in _ Snohomish __ County, <br /> to beg�n in the Sectlon 5 Towiship 28 Nonh: Range 5 WesUEasl W M <br /> and end in the Section Township North:Range VJesUEast W.tJ�. <br /> Fees in the amount of 5 0 are paid to defray ihe basic administralive expense incident to the proce:sing of Ih�s <br /> apphcation according to RCW 47.12.14D(2)and amenCments The app!icant furiher promises to pay adddional cosls <br /> ncurred by the Oepartment on the behalf of the applicaM. <br /> Checks orMone Or rs e to be made a able to "Washin ton State De artment of Trens ortation." <br /> � <br /> Apphw., (Re(crre as Gran'ee) Apphwnl Aulhotized Signalure � <br /> r <br /> Ad�rPss Print or Type Name <br /> City State Zip Cotle Ti11e <br /> Oatedlhis Oayof <br /> Teiephone � <br /> A licant Re�erence 0 Number Federal Ta�ID Number or Social5ecurll Numbei <br /> Authorization to Occupy Oniy Ii Approved Beiow <br /> 7he Washington State DepaRment ol Transportahon re!erred to as Ihe'DeOartment,'hereby grants this PermA sub�ect to Ihe terms anA <br /> cond�tions staled in the General Provisions,SDeaal Prov�s�on,, and Exhibits altached hereto and by this relerence made a paA hereof <br /> Constmction faulilles proposetl under ihis application shall begm wJhm one year and musl be ccmplMed wAhin three year5lrom Cate o1 appmval. <br /> For Department Use Only <br /> Exhlbdskltached Departreien p roval <br /> EKhibit "A" Special Provisions <br /> I:xhibit „13„ Sitc Map ey _— ��_���— <br /> f:xhibit "C" Dischargc design plan JC=hn Telleabo <br /> Title:�Q'Yc-^�"����iev•••� t Sr,/d2.LY "� <br /> Date: _G�.��/ Z _ <br /> Expiration Date _,�' / _------ <br /> DOT Fo�m12�L98EF Page. lot2 Pcrmi1GP061412 <br /> NeviseE S/09 <br />