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AFPLICATI03Q FOR IWCROA <br /> 1. CBMIMT P$RMIT <br /> PLEAS$ PRINT <br /> Date as n <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> /'�(/�/ <br /> Dep <br /> Jeprartment of public Works JOB REFAPN <br /> # <br /> I 6L� ' .3O B �{ EMP. i CK" # <br /> VALLID <br /> (APPlicant Name) /S DRIYS9PEyS: <br /> STREET <br /> �O t] � sj-o n! <br /> x 3 ---�_ QUAP _mss <br /> (MailingAddress) TYPE zvwrAL( * ---- <br /> // <br /> FORMS vs <br /> S TVDK �_I`i / �Zy NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone. Number) <br /> Sketch (Detailed 1 ' <br /> p arc may be submitted) <br /> o � <br /> � _ o n <br /> 0--//4 4e"V <br /> a M ox i <br /> DM <br /> �.rr. <br /> o <br /> The undersigned herebyapplies pp les fox permission to excavate, c <br /> otherwi a encroach on County Hi hwa g onstruct and/or <br /> 5 y Im tel Way oxz the �o� �� <br /> approximatel gin side -of <br /> of feet./'�. Ec4S� <br /> follawin <br /> gwozk escxiption of work) : by Pezform?ng the <br /> I <br /> Work 'l1 commence on oz about <br /> p <br /> days. for approximately_ I <br /> Ithe undersigned certify that I <br /> qualified to represent the am the owner of the respective property, or am <br /> accordancewith the rules owner and agree to do the work described above in <br /> wi regulations ofSan Joa <br /> in rection and approval. gain County and subject to I <br /> Sigzture of App23c�t _ Title V2_ <br /> +msrsa.ES\Pegs®y (s/ooh Date <br /> i <br /> -�' ye -Ap i? �d � 78 C/4/ <br />