Date:
Public Works Department
Town of Goshen
P. O. Box 187
Goshen, CT 06756
Attn: Public Works Supervisor
Re: House # and Street
Driveway Permit #
I hereby request a refund of my driveway permit payment of $1,000.00 .
Please mail my refund check to the following address:
PLEASE PRINT
Name
Street
P. O. Box
City, St, Zip
______________________________
Homeowner/Builder
This driveway has been inspected and the payment may be refunded.
________________________________
Public Works Supervisor
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