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FRO.°'1 :CAL I FORN I A I,,IATER SERI!.1 CE FAX NO. :2094640195 Nov. 21 2008 04:05PM P 2 <br /> APPLICATICK FOR ZRCROACBMWT PERMIT <br /> PLEASE PRINT <br /> Q <br /> Dateq 1 - <br /> OFFICE USE ONLY <br /> TO: San Joaquin County a0g <br /> Department. of Public works APIT <br /> Cg # <br /> Exp, DATE 2-1.09 <br /> VAL2D (1•ai•o To 2• .of n�AYs: <br /> {Applicant Name) 87=T -Xy'Y AVA. <br /> AM 2mm QUAD <br /> TY1�B � <br /> Mailing Addrosa) FORMS <br /> _�Q'(1 .• �..� r3,i`�� NOTE <br /> (City,"Statp, -Zip Code) <br /> acs � ��,� ��tr • <br /> (Area Code - Telephone Ntuaber) <br /> Sketch (Detailed p•1a'28 may be sWmi.tted) <br /> Tie undersigned hereby,applies for <br /> o'theswise-encroach-an Gaunt Pe=issiOn to.exca•aata, construct acid/or <br /> 3�U Y K\I y'Ri-Oway P4gh�-of-way.oa-the <br /> o£ , Mill,, approacimately 1 Ise <br /> fol to <br /> �0 Ark {t-escxxption of-T P ;Wolk) : r by the r <br /> work wi].1 commeacle on or'about; <br /> £or Spptoximately <br /> i• the u ndera igmed certify, that x am•the owner Of,the rt'Sp6cti.ve -Property, oramaccorrdanc&mc to represent the owner enc agree to do the Mork described above in <br /> e with Che �^tL , regmZations'of Sara J0 <br /> inspection anti ap�aro agk4n cciunty and aubj ect to <br /> Sig lat=e of Applicant - Title <br /> Date <br /> >usrrrc.pr��ccc�rr. rs/oo) , <br />