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PlEASE /PRINT: <br />Date OFFICE USE ONLY <br />To:SanJoaquin County <br />.Department of Public WorkseeriEPM3n~L[L{Of <br />IAt"to!ic~oiln~.me)i <br />I.loLlo WYl-S"t k.!V-'e <br />(MI!UUiU1!J)Auiillwess) <br />~'i:f}~kA:t>fi ,eN q~:z.C)4f <br />ICiltlf,SI~lefzilfJlCoile) <br />l2~q]37~-qtf~2.-lAma Coull!!-1eiapl1olll!!lr1lIDJl~er) <br />Sketch (Detailed plans may be submitted) <br />JOB# <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />. <br />. <br />DRIVEWAYS: <br />* <br />Workwill eommenceon orabou!7-lfj -2.bt7(.forapproximalely 2.days. <br />Er0'O il-::u:;-.:lbi6'.. <br />I,the undersigned,certify lhat I am the owner of/he respective property,or am qualified to represent the owner and agree to do the <br />work describGd above in accordance with lhe rules and regulations of san Joaquin.County and subjeclto inspection and approval. <br />fZJ2uJL DOt .•;. <br />Signa/life of Jlppiicar»t"Tille <br />7-5 -;;:(()!tf <br />Dale