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APPTXf ATION POS tG tO�CMMqT FgRbdx',C' <br /> x�LBL pl_�IN'1': <br /> MIMUSH ONLY <br /> 'Co Bansoagita x> County JOS <br /> Department of public Wo' rke APN <br /> Qxv, DATE / D <br /> (App33cJlat 1�aZ11A) D�AXS: <br /> STREET <br /> AEtEA _TiQfl OA560 � � — <br /> TYPE Ze <br /> (mailing Addregs—�)� FORMS. <br /> NOTE <br /> (city, sbete, -zip code) <br /> (Area Coca® -. T4ileph,one Number) <br /> Sketch (D6t-ailed pl.arg may be aivbrhitted) <br /> I • <br /> a:re undersigned hereby applies for permission t.•o,exeavats, COnO:truct and/or <br /> v�'_x�ro:iee encroach•do •Caus�ty•Highway Might-of•-Way on•the �-�" Ln--A - <br /> 'evapproximately 1 eFT <br /> by performiAg the <br /> following work (description of: work} ; <br /> ox;t <br /> will. <br /> commence on yr'about <br /> for approximately <br /> days. <br /> w, <br /> the .UUdar4igned bertify' that I am the OMex' of the respective property, or am <br /> cva.lified to represent. the owner and agx'ee' to do'.the work described above in <br /> a.ccortlance with the rules, xeguZations 'vf san t7oAqu•ia Cvun,ty and subject to <br /> inspection and a rav <br /> r <br /> h <br /> • ?gz.m '1vA of Applf.ea±at - Title Da'tQ. - <br /> .1 <br /> 'i. <br />