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APP __ �`A T ION FOR ENCROACH11W <br /> T PERMIT /?2 <br /> PLEASE PRINT: <br /> /�/�� OFFICE USE ONLY <br /> Date /� JOB # //005 REFI/ <br /> APN - - CRV# <br /> To: SanJoaquin County IIi.Phway Department. EXP. DATE /6-- 1437 <br /> �e1GtQ,;,�� �qq De I c(�,•G, CS DC D s) VALID �K�8 TO DRIVEWAYS: <br /> STREET Bfi�/. 42a G 7— <br /> (Applicant <br /> -(Applicant Name) AREA Sr�a,� QUAD L / <br /> r� <br /> (�� TYPE " 80.c�.✓c _ <br /> POUJE�rf �l Lt R�` �• FORb:IS <br /> (Mailing Address) NOTE <br /> (Ciq, State Zip Code) <br /> (Area Code -Telephone Number) <br /> Sketch(Dectailed puns may be submitted) <br /> O 'T: <br /> cz <br /> V. C-) rn <br /> Z LLCD <br /> - <br /> N Q <br /> O <br /> - � O <br /> The undersigned hereby applies for permission to excavate, constnjct and/or othenvise encroach on County <br /> Highway Right-of-Way on the No27-11 sideof_aP,Xttmi". 1k4T ,0911le _approximately <br /> C U ee /mile Ei9sr_ of 6i �vS_� -6ae e , by performing tli <br /> following work: (description of work j: ,9d o Ar-e e m o—7- / sa i 4 24,004 - <br /> Aid re w ) rci < <br /> Work ,Fill commence on or about Tv Nc /7 , for approadmately / days. <br /> I the undersi_aed certify that I am the owner of the respective property, or am_quaHed to represent the owner ai <br /> agree to do the work descnbeil above in accordance with the rules,regulations of San Joaquin County and subje <br /> an <br /> to inspection d approval. <br /> SIGNA F APPLICANT - TITLE � DATE <br />