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APPLYCAxTON FOR WCROACMaN'.E' PERMT <br /> Date OFFICH Uss ONLY <br /> TO: San Coaquin County L70E ## 30- x- Rap # <br /> Department of Public Works APS C� # <br /> VALID 3-1-0T- To S 1 O DRIFE'GPAY$s <br /> (Applica t Name) STREET e-t::* .L AVE . _.. <br /> AREA 6Ta-Acr,',V <br /> TYPE bLF- <br /> y, (MailingpA,ddxessss)� FOW48 55 ww r� -2f ......... <br /> NOTE <br /> (city, shote, .Ziv Coda) <br /> (Area. Code Telephone NumYiex), <br /> sketch (Detailed plans ,may be submitted) <br /> The undersigned hareby,applies for permission to-excavate, coast et and/or <br /> otherwi e-eacroach•on County Eighway Right»of�-Way..on-the a +�..Q �_• . <br /> !, approximately \7C's 1 <br /> of t> , ' .,. . , b 'peVfo=iz1g the <br /> ollowing work ascription of work) . - M T <br /> Work will comacmence on or'about f r approximately <br /> oQ days. ' <br /> I, the undersigned certify that x am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the vioxk described above in , <br /> accordance with the rules, regulations'of San Joaquin County and subject to <br /> inspection and approval.. Cz-'M-Q�l <br /> �'Xwl"IV\ <br /> sm <br /> Sigzmture of Applicant Title Date <br /> i01STlA.P9 SIL WOO) , <br />