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2J.P/t OFFiCE USE ONLY <br />To:SanJoaquin Cdilnty <br />-Department of PublfcWorks <br />PM 3 11 l>3 q 5"3.(Apll!icmi,n~ame) <br />'1oLlo tV"6J.S't k.~e <br />(lIJlaD~iU1gAiJIlHrass) <br />5.>1:p e}.G-ttH!j,t!J'r q~~oi..f <br />(CillJ,State;nlll Culls) <br />(;z "qJ 373.-1'1-~~iArrolCoiJe -I eiepl1iJi!e Nllml1ler) <br />JOB# <br />APN <br />EXP.DATE <br />VAliD, <br />sTREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />. <br />DRIVEWAYS:. <br />Slmtch (Detailed plans may be submitled) <br />-The undersigned hereby applfes for permission to excavate,construct andfor otherwise encroach on Counly Highway Righi-of-Way on <br />the N side of ~A"""'tG-t;.rb''t~Ret approximateiy /031:),GIImile W <br />of t 8-qA ,LOA:::r ,by performing the following work (description of work):, <br />Work wiII commence on orabou!7-18 -20£6'-for approximately 2.days.ErJO /I-;W-:J.bt£..,I,the undersigned,certify that I am the owner onhe respective properly,or am qualffledto represent the owner and agree to do the <br />work described above in accordance with the rules and regulations of San JoaquIn-County and subjectlo Inspection and approval. <br />IIIiI <br />I!I <br />I <br />I <br />I <br />I <br />!Z~OrA":"Signature of Applicant.Title