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SAG P CI lOW, FOR Elydmo cC`7�vJcW1 r2: V <br /> PLEASE PRINT: <br /> Date Q- 21— IS— OFFICE USE ONLY <br /> To: San Joaquin County JOS# �� � -7 �2" Z- REF# <br /> Department of Public Works APN Sr s __ <br /> CR# <br /> PM EXP.DATE. <br /> �U F 3 I► 3 �' VALID TO , DRIVEWAYS: <br /> STREET <br /> AREA QUAD <br /> IJLL 4/,o SS't L a K 2 TYPE <br /> Ad,Fl ess) FORMS ��/`(A)uij <br /> NOTES <br /> (Uij,Srate,zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> '� ' -to Row �` slbccld�t' rmad w01-f'� <br /> � w <br /> �Fo A '1 <br /> r � <br /> r--P c A Rrt y C 40 <br /> Wvrlc �✓`io_a �� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway ight of WAy on <br /> the I,n/P 4+ side of��lon B r,l t Ott approximately > O _ eel He %V <br /> of A r?r,�, t p t,� t� by perFom�ing the following work( escription of work): <br /> u 2 orEc <br /> Work will commence on or about //- 2 Z d G S _for approximately days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title — - . ! !S <br /> Date <br /> 73 <br /> MICENiRALEaMCESICURIWWUBSU.y K%%SEER-p'ZNCROACIO&WPMW(APPUCKnONAOC(09!13) <br />