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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASB PRINT: <br /> OFFICE USE ONLY <br /> Data 31 0 5 JOB H 1140S REF# ' <br /> APN - CRV4 eD W0 6 T <br /> To: San Joaquin County Highway Department._ EXP. DATE '�l •I a5 <br /> VALID-1.13.407 TO 9.1-CY5 DRIVENVAYS: <br /> Ac1vAniCeD �rFO �ryv;t�nhlen l � ST'REET '�Imw� aucr�uC " • <br /> (Applicant Name) AREA - r QUX(D <br /> TYPE <br /> 837 SMA W PoAJ) FORMS w <br /> "t (Mailing Address) NOTE <br /> q <br /> CSF <br /> o�r Q 9521 r <br /> Ci{yState ZipCode) <br /> 2a - 467 - <br /> ` :. (Area Code-Telephone Number) <br /> - Sketch(Detailed plans may be submitted} <br /> dof TTVc1110 n <br /> TE- <br /> r' <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County <br /> HighwayRight-of-Wagon the WAL+ 5+ sideof elmwoa0 Aveme_ approximately <br /> So' i5- •£2s- 0/mile WFsi of </NW9nf� by performing the <br /> ollt�o g work: (description of work j: S o o 'n '25 ISSG AS <br /> £P f RrT /.ttWD w9fK PIR") /A <br /> 5irc ..i <br /> Work will commence on or about 2-DQ -5 for approximately a days. <br /> I the undersigned certify that I am the owner of the respective property, or am qualified to represent the owner and <br /> agree to do the work described above in accordance with the rules,regulations of San Joaquin County and subject <br /> to inspection and approval <br /> 4 PROD) <br /> �• ._ SIGMA I I I &OF APPLICANT - TITLE <br /> DATE <br />