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r MLJ1 I NHL-1 r Ljm. i 1 H WH I CK 5['KV 1'.,C r H1�, IVU. =�U V4b4VJ 173 J un. G7 G!'JVJ f J4•J Y'I'I r <br /> APPTAXCATMON FOR MCROAMMT F$RMIT <br /> �? F;ASF.� PRINT• . <br /> Date `•J� OFFICE USX ONLT <br /> To. San County am # 7507 REP $� <br /> Department of Public Works AM CR � <br /> -4-41 —� <br /> VALMxp /S-D 7 DRIVEWAYS: <br /> (Appl.icamt Mame) SIAM �D�✓mJ� <br /> AS,50W -TVMA%T5T AMM <br /> (biailiag Address) FOM �vcy1 -z9 �-- <br /> StbC .a � C'c� CZWD I Nom <br /> ry(City, State, .zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed ilans tray be submitted) . <br /> The undersigned hereby appl,:.es for paaz=ission to,excavate,.- constz at axed/or <br /> o ne• c7roach oa cauncty S gbway :Right-of the <br /> of <br /> approximately �� e m{� <br /> ' bY'performing the <br /> following ork (description of work): "11- . <br /> r <br /> CA <br /> N'Ork will Comeace on or•aboutio r approximately <br /> days. <br /> z, the uaderaigned cexti,fy that x am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the Mork descr4bed above in , <br /> accarcbnce with the rules, regulationts.of San fl'aacru3n county aad m!bject to <br /> inspection and approval. <br /> Signatu�Applicautxitle Date <br /> �asr�.Dsla�sc�>; t6/ooS . <br />