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A-TEF' =EF .TE H. J! 20540.10 J __ +h11 p - <br /> A.PPLICATXON Ton ZMCRO,&CENNT PEPRIT <br /> z k4 <br /> PLEASL PRINT <br /> Date OFFICE ME O2MY <br /> To: San aoaquin co=ty nos 73on" 7 RE] <br /> Department of PLIblic Works A.pN _ { <br /> " Ems'. 1?Z1'I"E '2 S i0 <br /> vx� j o M t o io is o_ a�rvsw�►Ys <br /> {Applicxsnt Name) STREET • <br /> •150� �'��_ ��n s Y' <br /> Mailing Address) FORMS -2 -- <br /> �N' IPA NOTE <br /> (City, Stlate, .Zip Cade) - <br /> (Area Code - Taiaphone 'number) <br /> Sketch <br /> (Detailed p)anz may be submitted) <br /> l� <br /> The under-signed hereby applies for pezjssion to.=c'avate., construct and/or <br /> otherwise-encroach•on •County.I ighway Right-ai'-Wa o'a the ILLE•0+ bidC:.of. <br /> approximately lEvr2iie� :§ t " , - <br /> of r qua. '• 1. . by-pe forming the <br /> following Mork (description of, <br /> work) . <br /> Work will commence on or`about for appxaximately <br /> days. . <br /> T the undersisned cextify, that I am the owrzex of,the respective •propel.-ty, ax am <br /> qualified to xepxese= the owner and agree to do the work described above in , <br /> accordance with the rules, =eaulati nz•of San sosqun Ccunty and subject to <br /> i spection and approval. <br /> signature of Appl.ic=h - TitZa Itin <br /> F <br />