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_11 �I ILaI LJI.I111� W!-IILI\ JLI\V 1'..L_ 1 I"'I!1 IYV. GV JYV"t CJ1 JJ J I.Al 1V G_JI t� c _i li r_ <br /> ,A,PpLTCATTO FOR M;MOA T <br /> . �� <br /> Joh j 730 77 SSP' # <br /> TO: saw Jos tiY JON m , <br /> DeparrtMent: 9 APub�'.�io Works c . �l IDII I �o 97 <br /> STRUT ICPn�ra� s+$ <br /> (APPUo ant, Names) Qt71�p �' <br /> Alm <br /> FORMS <br /> (�a9,Xiag ACldsAsge)� ROTH - - ♦ <br /> (City, State, <br /> ,.Zip Coda) <br /> (Area Code Telephone V=ber)• <br /> sketch (Detailed ilaw may be subioi tted) <br /> The w>u ersigmed hereby,applieg for permission to,excsrvate, Construct axed/or . <br /> •encroach ar Cotlty-sighuraX Right-of-7 ••=• 8i.d�„o,�; <br /> ovse fee \tV F�� . <br /> appmximate3-Y 13 pe g the <br /> following workdescxf tion k)s <br /> It °�C -- <br /> «4 <br /> work will ooaamalxce on or'about for •approximately <br /> days. <br /> x, the undersigned certify that l am the owner of the respective property, oz ane <br /> qualified to represent the owner and agree to do the vaoxk descrited above in , <br /> accordance with tate XUV, regulations♦of Sate joac n County and subject to <br /> i•aspecti cn and approva l z�-Vi-<6 -' <br /> Sig=t1=0 mue Date <br /> �max <br /> ►asr�.asWk <br /> 4/001 <br /> ' t <br />