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FPCIM :CH-L I F IPH I P I;,IHTER ;SERV I..E: FRX hJO. :22094640195 Ju 1. 2'E' I G=I : I'qPM F <br /> AFPLIOATIOX FOR ENCROAMEN''i` PERMIT <br /> Date OFFXCE U59 ONLY <br /> ma: San Jaaquia County JOB 0077 Rg # <br /> I)epartment of Public 'forks A29 <br /> Exp. DATE d0-t5-off <br /> vnm 7-3-o x 0-15-6A <br /> (Applicant ga=e) STMT [x]=`QE M. <br /> ARRA , QUAD <br /> (Mailing Addrotaa) FORMS r ' <br /> NOTE <br /> (City, q'Stat(e�, .Zip Code) <br /> G <br /> (Area Code - Telephone Number), <br /> Sketch (Detailed plazas may be subtr:,.i.tted) <br /> IDVa undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise'-encroach•on 4county aighway Right-of-Wa ••oa the NQ s'ide;.of w' <br /> approximately f me W'C= <br /> of L�'A 1�- �0..� R"�!'�`�— `' x►Y peYEo=in9 the <br /> following work '(desCxiptioa of:work) : l - <br /> Work will commence on or'about .C -1 ` '"Ca$ for approximately <br /> days. . <br /> S, the uadersigned certify t1Iz.t I am the owner' of,the respective -property, or am <br /> qualified to represent the owner andagree to do the work descried above in <br /> accordance with the rulef, regulations'of San J'oac,�x= Cnunty and subject to <br /> inspection and approval-.(:a..N4-4t <br /> Sigznatuzo of Applicaxat Title Date <br /> • 4 <br />