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APPLICATXON FOR EXCROACMOM PERMIT <br /> tTF <br /> Date o—__� <br /> TO: S<'tn Joaquin Couaty JOB #) "7 �7 REP # <br /> Dc5pa.rtment of public Works APIA clZ #� <br /> W. DATE 12-1 -o(o <br /> CI����cORNII� \I�t ATOP% SSM a VALID• li-1.. 3� TO DYtr=AYS: - <br /> (Applicant Name) Ae AJ6. <br /> ARBA •�•r�lcra�/QC1An , r� w <br /> TYPE 7=6 CL 1.4g,�L& <br /> (Nailing Address) FORMS _az�� <br /> ��.� N'OT'E , <br /> (City, Sbats, .Zip Code) <br /> (Area Code - Telephone N,'tmaber)• <br /> Sketch (Detailed plans may be submitted) <br /> �v� <br /> T6 undersigned hereby applies for permission to.excavate, onotruct and/ox <br /> oIle "s -encroac ozm Cotnsty Highway Right-of-way•on•the � • sidp,.•of <br /> U '� approximately t�� r 4 <br /> of , �. , by per$ormirig the <br /> followin work criptio of work <br /> ti <br /> Work will commence on o44.Aoxxt `O�,` for approximately <br /> days. . <br /> 1, the undersigned certify that z am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above :in , <br /> accordance with the z'v3te s, regulat ons'of San Joagudn County and subject to <br /> inspection and approval10\-C 8, 01 <br /> \X-%\Q� <br /> Signature of Applicant - itle Date <br />