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PLEASE PRINT: <br /> f <br /> Date ; 9 �` c i POf FffrMOKY <br /> To: San Joacuin County JCS# REF# <br /> Department of Public Works APN <br /> OR# <br /> EV:DATE r ,,C _ <br /> _.. '(Applicant NarYte) STREET � • <br /> y ..� "._ AREA <br /> TYPE <br /> (Maillr4 Address) FORMS <br /> NOTES <br /> (City,Stat6,Zip Code) <br /> (Area Code-T Wptroneo Numbercr))/`( U/' <br /> Sketch(Detailed plans may be submitted) <br /> �• i <br /> I <br /> The undersigned hereby applies for permission tDe=avate, n <br /> the E" _side of L-22*W-e— A <br /> of �✓ /.:'r, — 9 � F t3f worFc). <br /> r• <br /> Work will commence on or about days. <br /> I,the undersigned,certify that 1 am the owner of the respecft propedy,or am qtp*W bd repr ctl -- #i1jpW�b do the <br /> work described above in accordance with the nrles and r+egutabms of Sw Joaq*oft*ar 24ft hraiii�qvovei. <br /> Signature of Applicant-Tine vDft <br /> L%PUPSVYWAWTR PS*NCROACHhuINT PEFWT APPI CATION.00C (oV*I <br />