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APPLICATION FOR BNCROAC PERMIT <br /> PL r PRINT: <br /> OFFICE USE ONLY <br /> Date '"� <br /> JOB # REF # <br /> To: San Joaquin County APN CR # <br /> Department of Public Works EXP OAT j8-l�� <br /> VALID r TO Zai._._- DRIVI�9PAYS <br /> ICI h�I <br /> '�uPt»cI�/' STREE <br /> (Applicant Nasse) AREA <br /> TYPE <br /> n CO FORMS <br /> (Mailing Address) NOTE <br /> (City, State, Zip Code) <br /> (,Area Code - Telephone Nvsaber) <br /> Sketch (Detailed plans may he submitted) <br /> s.4.� <br /> IP-4 A25 <br /> ed hereby,applies for permission to exoavate, n et and/or <br /> The undersigned Right-of-W oA the <br /> otherwise-encroach on County approximately — f eta <br /> To,�v�• by "performing the <br /> following work (description of work) . �� <br /> for approximately <br /> - <br /> Work will commence on or about <br /> �f-Z/ rP <br /> days. <br /> ert or am <br /> I, the undersigned certify that I am the owner of the respective property, <br /> in County and subject to <br /> with the rules, regulations of San Joaqur and agree to do the work described above i <br /> qualified to represent the owne <br /> accordance ' <br /> inspection and approval. <br /> Date <br /> Si tune of Applicant - Title <br /> MASTSR.PS\BSSSMML (6/00) <br />