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6FP-28-201 1 (WE0) 06: 28 <br /> P. 002/003 <br /> .... ..... r r r w.. .r r r. u v u u u♦ {.....! u{ J I u Y r� r.+r r • J U V <br /> 2095781974 M 5t.,Modesto Ca .08;55;32 a.m, 04-23-2009 212 <br /> APPLICATION POR =CROACBMENT PERMIT <br /> PLEASE PRINT; <br /> Date 7'-29-/1 omacg vas 02MY <br /> Ta: -San Joaquin County _ Z !!"� REF #_ <br /> Department of Puhlic Worko # <br /> / ��// <br /> EXP. DATE / <br /> ;ccm e/ W 6VALID /// O &e2z& DR2VMMYS i <br /> (Applicant Name) ~ STREET 4A • * <br /> AREA QMW _5A) <br /> (Mas]ifag Address) FORMS 1d <br /> NOTE <br /> (CIti, State, Zip Croda)209' <br /> (Area Code - Telephone N=bar) <br /> sketch (Detriiled plans may be. submitted) fIG1 a� <br /> The undersigned hereby applies for permission to excavates, construct"'-and/or <br /> otherwise encroach-on County•-Higl way Right-of-•Way on-,the - -side- -of. - - <br /> proximately /6A!0:9 <br /> of by performing the <br /> following work (description of work]: A—gt!r, ��r+•d�c� _{ "A- <br /> Work will commence on or about 70- -// for approximately <br /> days. <br /> It the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of Scan Joaquin County and subject: to <br /> inspection and approval. <br /> 'tura of Appl3Cant - Tide Data <br /> Ma•'• A.Pslr"SQ= Is/ouy <br />