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.b 03 08: 41a Valuen UUSTIomer --- ---- - <br /> APPLICAT-T, _- FOR -ENCR@ACRXXNT- "117T <br /> PLEASE PRINT• J <br /> Date +1 C�-O� OFFICE Ugs ONLY <br /> To: San Joaquin County JOB 4 RHr # <br /> Department of Public Works A211 ._ # <br /> Oi1k �Ac�-�l Of FA_L1 my SvC1 E T y EXP. DATE d OG► <br /> D L 4US-A PrPE CidS�c�Eri� vALID- T � <br /> - DRI�YB <br /> (Applicant Name) STREET <br /> AREAT#e,�ta iuJAa <br /> TYPE <br /> (Mailing Addroa ) FORMS <br /> QR It <br /> t;,Sig 3 a-, NOTE <br /> (CIty�, S-t-Ia�j- Zip Cad-ol <br /> - 2'4S - Ingto <br /> (Aran Code - Telephone Number) <br /> Rketch (Detailod plana may be submitted) <br /> o . • <br /> SEE at6u_hEbcoo <br /> s <br /> -0 <br /> co crn <br /> a •• <br /> R <br /> to <br /> Ther Underaigned-hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the aidfa_ of. <br /> approximately feet/mile <br /> of <br /> '. by.performing the_ <br /> follow <br /> ing work- (description-of wvrki-: <br /> Work will commence on or about for approx <br /> dyn= <br /> I, the undersigned certify that I am the owner-Q£_thW_rAspeetive-p=opert� �— <br /> qua-tified to represent the owner and agree to do the work daacribed above in <br /> accorddiice with the rules, regulations of San Joaquin County_ and_guj;}ect t0. <br /> inspecti-ow and- approval <br /> IL <br /> Signa urs of Applicant - Titla nate <br /> vsc�rtemc WOO) <br />