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F?OM :CF'_T FORfd T c I,,IATER SERVICE FA,'' NO. :2O94S4G"95 Ta.n. 1 ��^ '' 2 <br /> lei <br /> Oa'te 1110 l Od L'ZCE US3 ONUAT <br /> i <br /> San C'aaquia County am !7go0 77 pm- ___--- <br /> Department of Public works APN C <br /> MLP <br /> . DATE. 5'!/ <br /> {APPliaant N'sma) STREET 144 sp _ <br /> � Q T'PR tt. NOtL� <br /> L aiZfxig Add7casa) FORMS 5T Ly , R-2,5. . <br /> NOTE <br /> (C3t7, State, -Zip Gods) ----- <br /> {Ates code - Televhona lz=ober) - <br /> Sketch (Datailed plans may be sw=itted) <br /> The undersigned hereby,appl:ieg for permission to.excavate, construct and/or <br /> ath=V i.se-encroach on County.Highway RAglat-of-%by+•on•the _ g <br /> . approximately E W b f ee mil* to <br /> °f bgr pe'r'f'ormjsior the <br /> foll.og work (description oi;work) a <br /> SIA-4- <br /> 1 <br /> Woxk/will co=erce an or, t i for approxi�ratelX <br /> ��� '. . <br /> Z. the undersigned certify that l: ata the own.ar' of,the respective ' ropexty, or am <br /> quali.fi� to represent the O=er and,agree to do the work described above in, <br /> accor4bace with the rules, xeq-t Iatiozas-of Sa r �oagti�s� chanty and subject to <br /> erection and. approya� ' <br /> Signatur4 0E Applicant Tits Dat <br />