TOWN OF GREENE PERMIT FOR FILL                     12-  ________

APPLICANT ___________________________________________________________

ADDRESS ______________________________________________________________

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MAP ___________                                         LOT _____________

LOCATION ____________________________________________________________

ZONE _________________________________________________________________

SOURCE OF FILL ______________________________________________________

TYPE OF FILL _________________________________________________________

CONTRACTOR _________________________________________________________

SPECIAL CONDITIONS _________________________________________________

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DEP APPROVAL                              YES                                         NO

EXPIRATION DATE _______________________________  FEE $10.00

PERMIT MUST BE SIGNED BY ONE OF THE FOLLOWING:

___________________                      __________________________________________

DATE                                                     TOWN MANAGER

___________________                      __________________________________________

DATE                                                     RANDALL  RAY, CODE ENFORCEMENT OFFICER