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TION FOR RRCROAC T PERMIT <br /> APPLIGA, <br /> PLgASB PRu T_ crss ONLY <br /> OI?rT g <br /> Date JOB # CR: # <br /> San Joaquin County APN d <br /> To: public Works pXp. DATE DRIVSW S=. <br /> Department of PubTO <br /> (Applicant Name) <br /> ARRA <br /> C c�o°�TC 4,g- TSE ss� <br /> FORMS <br /> (Mailing Addrdsd) NOT's <br /> S�otl�-�0�1 C5\ <br /> State, .Zip Code) <br /> (City. <br /> (Area Code - Telephone Number) <br /> Sketch <br /> Detailed plans WLY be submitted) <br /> ssion to.excavate, construct and/or <br /> Ems . side._of <br /> ed hereby applies for Pe ght-of-Wa oa•the �Q�v'� <br /> The undersign Highway � ee <br /> otherwise"encroach-on C,� ty aPProtely formit3 the <br /> , . <br /> ofof work) : <br /> following descr <br /> war (�E� tion„ C a.' 5� Qom\cg0 . 3 <br /> for approximately <br /> Work will commence on Or about <br /> �® days. or am <br /> that I am the <br /> owner of the respective property, <br /> ee to do the work described above n . <br /> I, the undersigned certify d eject to <br /> to represent. the owner and agree <br /> San Joagv:in County an <br /> qualified regalati07 <br /> accordance with the ru]es <br /> inspection and appro`r�7-.�Ol <br /> _ Date <br /> Signature Of App <br /> licant - Title <br /> ��.PS�ggg^aC�L f6�061 ' <br />