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APPLICATION FOR R4A T PL4R�IT <br /> Rum x <br /> Date ! ' os`ncx USE ONLY <br /> To: San Joaquin County JOS # flU � REF # <br /> Department of Public Works APN _ CR . # <br /> ^i-. f <br /> Exp. A' N <br /> A A. s test VALM / To DA3C Ys: <br /> 1046t Nems) STREE �]�� <br /> T ' <br /> QM <br /> REA 'M <br /> TypE <br /> (Nailing Address) / FORMS <br /> NO <br /> TE -- <br /> (city, strata, Zip Code) <br /> (jcode - Telma mer) <br /> Sketch (Detailed plans may be submitted) <br /> s t. % a� <br /> 'S u AA AA <br /> (S <br /> 9 1f <br /> Y <br /> a1. ( cad j q c,�r- �S <br /> The undersigned hereby applies for permission to.excavate, -const ct and/or <br /> otherwise-encroach on County Highway Right-of-Way on the • aide 'of <br /> approximately feet/mile <br /> of by 'Performing the <br /> following work (description of work) : <br /> Work will commence on or about t9 for approximately <br /> S) days. <br /> 1, the undersigned certify that I am the owner of the respective property, or sm <br /> qualified to represent the o*mer-and agree to do the, work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> i repecti.on and approval. <br /> i ((( <br /> 1 / IS 1C <br /> s gssa,turo of applicant, - Title Date <br /> MRBTBR.MzMS®L (6/00) <br />