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APP#ATION FOR ENCROACIEVWT PE.FLIN IT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date 3 - 7 - `/` 7 JOB 9 r3 e 7 7 REFH <br /> APN -_ - CRV# <br /> To: San Joaquin County Highway Department. Exp• DATE 5/ <br /> VALID 3 13 TO s DRIYEtiYAYS: <br /> STREET P0 cv/,///,/c;;: �yF <br /> (Applicant Name) AREA QUAD J1 E�, <br /> Gd `Su, /D o TYPE T,e ,mac s <br /> FORMS w <br /> (Mailing Address) NOTE <br /> Z/. 9!---,Zo 3 <br /> (City, State Zip Code) <br /> 1-2017- 446-1-0511* f101�/2SS- <br /> (Area Code-Telephone Number) /9i"/-L/Ci9T�0/V 4-55. 5 <br /> Sketch(Detailed plans may be submitted) <br /> _ • • 'r= <br /> Cn <br /> n <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County <br /> Highway Right-of-Way on the _S side of 0 A approximately <br /> /(', feet /mile L-= of 4-r r' /. �— ,by performing the <br /> Mowing work: (description of work): /t. <br /> Work will commence on or about -/ - `1 I for approximately v 'c? days. <br /> I the undersigned certify that I am the owner of the respective property, or am qualif ed to represent the owner an( <br /> agree to do the work described above in accordance with the rules,regulations of San Joaquin County and subjec <br /> to inspection and approval. <br /> SIGNATliRE OF APPLICAINT - TITLE DATE <br />