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._ _.. _ .. �. =CR'✓:.'..� rHrI`li_i. w_74br-{bJy_y�' HiU9. 1t, GVM_y bJG. <br /> APPLICATION FOR =CROACMENT PERMIT <br /> PL,�SE PRINT: . <br /> Date LAL3�. �� � OFFICS USE OIMT <br /> To: San Joaquin Co=ty 170B # �_ RLQ' <br /> Department of public Works APN CR # <br /> SXP. LATE <br /> VAI,TA TO /-2 . DRIVEyaAXS <br /> (Applicant Nmma) . STREET !r^:!p,(;y1 ID., <br /> AREA SAD C C_. # <br /> (�ai.liug Addroa►rt) FORMS Z <br /> (Catty, State, ,Zip Code) <br /> (Arum Code -' Telephone Numober). <br /> sketch (D6tai.led plan mar be sivbmi.tted) <br /> The undersigned hereby applies for permiss,'axe tO,Oxaavate, construct and/or <br /> otherwise•-emcroach•on Coum X <br /> 1_ ghway 1?ight- <br /> OTNI Of-W&y+•ax•the <br /> of �.., A�?\tib' approximately <br /> fallowing work (aescripti.on Of;work) ;• _ b'Y'PeYEosrni g the <br /> Work will ao=enceaxz or' m <br /> about - - <br /> --- <br /> days.', for appxoacimately <br /> I, the and xsigGed cextifyr that I am the owae�r <br /> qualified to of,the 'respective property, or am <br /> represent the owner ancl, agree to do the work described above'in <br /> r l <br /> accordance with the r�:Les, <br /> inspection and a Agree <br /> San Josgn4n CPunty and subject to <br /> ppxo•va3..L�-6,R.Com) <br /> Z-19nature of Applicant - Title (3 1 <br /> Date <br /> • r <br />