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APPLICATION FOR ENCROAC24MiT PFRMIT <br /> PLEASE PRINT• <br /> Date `\ a�$ OFFICE USE ONLY <br /> To: San Joaquin County JOB R$F # <br /> Department of Public Works APN C1Z # <br /> CA1_1 FORNIR �N RT�.R SUW "—ATE '7-/-06 <br /> TO _2Z&0__6 DRIVEWAYS s <br /> (Applicant Name) STREET N?ir jt) �y + <br /> AREA QUAD _ + <br /> TYPE + <br /> `J (Mailing Address) 52S/,� FORMS / L5' <br /> Stoct�tol�� �� Iy�O 3 NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted.) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way••oa-the 'IN I , . • side -of <br /> approximately feet/mile ^ <br /> of by performing the <br /> following work (description of work) : <br /> zt3.STt�L1_ g,"Ft Rte. 5'E.FZV lC�. <br /> ���►t1lC� C� all X 1-i C,I INW- OX+ <br /> 3a3b 'N�. RQ�E�T" CS�J <br /> Work will commence on or about <br /> 1.r�0for approximately <br /> days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rulep, regul,ations'of San Joaquin County and subject to <br /> inspection and. approval <br /> �•N�AC'C�Pcm � �� NS C 1t�K dy -pg- <br /> Signature of Applicant - Title O$ <br /> Date <br />