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["別記様式第一の三（第五条関係）"]
[]
[]
["通行禁止道路通行許可申請書"]
[]
[]
[null,null,null,null,null,null,null,"    　　　　年　　　　月　　　　日"]
[null,null,null,"署長　殿"]
[]
[]
[null,null,null,null,"申請者","住所　"]
[]
[null,null,null,null,null,"氏名"]
[]
[null,null,null,null,"主たる　　運転者","住所"]
[]
[null,null,null,null,null,"氏名"]
[]
["車　両　の　種　類",null,null,null,null,null,"番号標 に 表 示されている番号"]
["運　転　の　期　間",null,"　    　　　　年　　　　月　　　　日　　　　時から　　　　　　　　年　　　　月　　　　日　　　　時まで"]
["通行しよう とする"]
["通 行 禁 止 道 路"]
["の       区       間"]
["やむを得ない理由"]
[]
[]
["第　　　　　　　　号"]
[]
["通行禁止道路通行許可証"]
[]
[]
[]
[]
["　　　　　　　　　　　　　　上記のとおり許可する。ただし、次の条件に従うこと。"]
[]
[]
[null,null,"条     件"]
[]
[]
[]
[]
[null,null,null,null,null,null,"　　　　　　　　　　年　　　　　月　　　　　日"]
[]
[]
[null,null,null,null,null,null,null,null,"警察署長",null,"印"]
[]
[]
[]
[]
["備考　　１　　用紙の大きさは、日本産業規格A列４番とする。"]
[]
["　　　　　 "]

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