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1_11`1 -._HL lh'1_1KIVIH t--HICK FH'; NI_. <br /> APPLICATION' FOR JWC!ROACMMM PERMIT <br /> PLEASE PRM; <br /> RM: <br /> Date �. 1 u� : aQOPPXCZ VSZ OULY <br /> To: Sari Joaquin County JOB RE' ## <br /> Department of Public Works AM Cg � <br /> EXI?. DATE <br /> — - VALECv :-c' TO DRMVAYS: <br /> {Applicant Namo) STMT /tom'-na <br /> Mailing Ikezress) FORMS <br /> NOTE <br /> (city, State, .zip Code) <br /> (Area Code - TelePlIone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby,applies for permission to•exaavate, construct and/or <br /> otherwise--encroach•on •couaty Xighway Right-oP�Way••o x the CS a'id�: o£ . • _.' <br /> approximately E � <br /> Of t' `s. _ 1. • ,, , by "pexformi»g the <br /> following work (description of.work) ' <br /> Work will commence on or•about CM for approximately <br /> days. <br /> .1, the undersigned certif that I am the owner' of.the r'espectiv'e -property, or am <br /> qualified to represent the owner and agree to do the work described above in - <br /> accordance with the rule:, regulations'of San Joaquin county and subject Co <br /> inspection and approval..C.`J4 ,tC %"b� <br /> Signature of Applicant Title Date <br /> t <br />