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APPLICATION FOR WCF20ACEMENT EERMIT <br /> PLEASE PRINT: <br /> Dana OFFICE USE ONLY <br /> TO: San r7oaquin County J©B # 730 S-2-4o <br /> Department of Public Works APN CR # <br /> EXP. DA -- - <br /> VALTZ) Z�f DSD TO 1 DRIVEWAYS <br /> Mpplicant Name) STREET + <br /> 446-AZSr ZAAOLZ APM)eAl ' QUAD �S <br /> .,IPE - <br /> w <br /> j.� (Xailing Address) FORMS S w w <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detai,].ed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ochelrw`ise encr`oach on County Highway Right-of-Way on the � atz gi a of <br /> �+1 �+te. appro_aimatel feet <br /> of _U by by performing the <br /> follo in work (descript'on of work) : 4D <br /> Work w'] commence on or about for approximately <br /> days- <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent thea owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval, . <br /> - 1 0� <br /> S:. ature or Applic6t '.Citla Date <br /> PME <br /> 4"G WNK Lmw <br /> E 'd E69PON STOOKON'GA iMM <br />