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APP TION FOR ENCROACHNOT PERMIT �1�3 <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Data__ ,�--%G'j' ;7JOB #_ 3 0 2 510 REF# <br /> IAPN - - CRV# <br /> To: San Joaquin County Highway Department. Exp. DATE 5- <br /> VAL1E 20 y TO ¢ 7 DRIVEWAYS: <br /> (PAC-1 i=iC fit=l-L- STREET Z-"/ <br /> (Applicant Name) AREA QUAD -S <br /> TYPE_ <br /> �E75 <br /> 'T---5i- Pb 6cJX >Sy3Crn� Dt-"s FORMS 5s Q -2 q <br /> (Mailing Address) NOTE <br /> (City, State Zip Code) <br /> (Area Code-TeIephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 70 <br /> co o; M. <br /> r C <br /> CD <br /> x _ <br /> cn <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County <br /> I-rsghway Right-of-Way on the V/1=S T side of approximately <br /> '73 feet /mile of j - 14;1 ,by performing the <br /> following work: (description of work): 141-14 = <br /> Work will commence on or about 3 -- 7 for approximately /O 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 /> 4SGINTATURE OF APPLICANt - TME DATE <br />