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APPLICATION FOR ENCROACEMF,NT PERMIT <br /> PLEASE PRINT.• <br /> Date ✓ �ff OFFICE USV ONLY <br /> TO: 'San Joaquin County .708 #. _?-�V'_ -3 REF # <br /> Department of Public .works APN <br /> A�- r�.�+ --- ---- B:7CP. DAVE -- <br /> "J'��' I VALID 3-7-0? TO _�.:_�"0 7 n12x V�WAYS <br /> �/� (Applicant Name) STREET GA 4LEY GT. <br /> 'S _ <br /> 9�Iv�-' i. I&Hlr MI C.(.r AREA TGC/GTU�QUAD ,t <br /> M <br /> (Mailing Address) FORMS 7l <br /> NOTA <br /> (City, state, zip code). <br /> 4- Lf/� <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 1� <br /> The undernigned hereby applies for permission to excavate ,, c nst.ruct and/or <br /> - o•herwise encroach-on County-Highway--Right-of-Way on the W .•�� - gide of <br /> 75 approximately I' ZIQ ee mile <br /> bv performing the <br /> following work (description of work) <br /> Work will commence on or about rQ for approximately <br /> days. <br /> X, the undersigned certify that T am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rulee, regulations of San 47oaquin County and subject to <br /> inspection and approval, <br /> gnatur f Applicant •- Tial TOO .�?• Date <br /> MAETEM.MS%rff ., (8/0u) <br /> Lo <br /> 2001200 d (0]W00P_H_ddW <br />