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<br />RICE CREEK WATERSHED DISTRICT <br /> <br />By_______________________________ <br />Administrator, Doug Thomas <br /> <br />[FULL NAME OF PERMITTEE] <br /> <br />By:_______________________________ <br /> <br />Its ________________________ <br /> <br />APPROVED AS TO FORM and EXECUTION <br /> <br />By:________________________________ <br />Its Attorney <br /> <br />Date: <br /> <br />Date: <br /> <br />Date: <br /> <br />3 <br />