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f <br /> APPLICATION FOR WCROACF PERMIT <br /> PLEASE PRINT: <br /> Date —J - 2_0 <br /> OFFICE Q98 ONLY <br /> To: San Joaquin County JOB # _73Q'� . <br /> ABN <br /> Department of Public Works REF # <br /> # <br /> EXP; DATE Q /Z. CR <br /> (Applicant NName) VALIDSTREETDRIV8101Ys s <br /> � <br /> � AREA 5'T�� �i �i/ KL� TYPEQUAD <br /> (Mailing Address) '�� <br /> FORMS -Z <br /> ST6C_ktz'�" CA <br /> U NOTE <br /> (City, Stato, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> << <br /> The undersigned hereby applies for permission to excavate; construct <br /> otherwise encroach on Count fghway Right-of-Way on the - P � and/or <br /> of approximately / side of <br /> C��/I���` /�h r eet mile 1L6,'t'`L+ <br /> following work (description of work) : by Performing the <br /> G �e ti , k <br /> Work will commence on or about <br /> ------- <br /> 3c) <br /> days, for approximately <br /> I, the undersigned certify that I am the owner of the respective <br /> qualified to represent the owner and agree to do the work desc a Property, yr am <br /> accordance with the rules, regulations <br /> inspection and approval, Joaquin County of San Joa xibed above in <br /> and subject to <br /> Signature of Applic - Title 42 C;2' <br /> Date <br /> xs:S7l FS`P7BSC1ML i6;'101 <br />