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F•RUM :CHL I F URN I R WATER SERVICE FRX N0. :20946401'3b t eb. 19 201.6b 04:17F'M r 4 <br /> pF$L CAxxON FOR MCROAC T PM T <br /> Date '. 071?XCE: USE ONLY <br /> TO: San Toaquia County rTOB REP # <br /> Department of Public Works APP C1FBIC0 <br /> c,i ATE <br /> l a To o , DRry AYS: <br /> (Applicant: Name) STMT 11*:~ <br /> Am wt!�Wxbm <br /> �'• - <br /> � S7 '-W\M TYPE <br /> (Mailing Address) FARMS Tw R-Z4 <br /> S�oc�K ol�1 CA �S&0 3 SOTS <br /> (city, statre, .Zip Cade) <br /> (Area Code - Teleph=6 mer). <br /> Slcet:ch (Detailed plans may be submitted) <br /> The undersigned hereby,applies for permission to,excavate, const at and/ox <br /> oche s ro •ort CO=ty gighway Right-of-Way.-on•the sial '..•of . <br /> approximately <Z_Q �a <br /> kv <br /> of u • .+ by performing the <br /> foilowin ork (deseri tion f work) <br /> Work vvi. commence on or'about ~ for approximately <br /> — -,g clays. , <br /> X, the andersi.gned certify that X am the owxxer of the respective property, or am <br /> qualified to represent the owner and agree to do the vioxk descriled above in , <br /> accordance with the rul s, regulations'of Sazx Joaquin County and aubject to <br /> inspection and approval Ocaz\10 a-1 <br /> Sigpta►tura of Applicant fttli Data <br /> �arr�a.va\vascros cc/cof , ', <br />