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APPLICATION FOR ENCROACMONT PXM11T <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> .r <br /> To: San Joaquin County JOB # IfsREF # <br /> Department of public Works APN q # <br /> ( ' EXP. DATE <br /> C i\l X `✓ ; 'f i { VAS "rVAItI17 /9 To f3-f-06 DRIV3lYS <br /> (Applicant Name) STREET <br /> 7 '� t AREA QUAD � + <br /> TYPE ! <br /> (Mailing Address) FORMS _ s�, �44Y <br /> } � 4:7NOTE <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.-on-t. side..of <br /> `, approximately -7 `109D__':�, mile rJ <br /> of T C-L ft^- v t�5sJ e�W'/•t 6&t ci 4,-#a ,`"A,`4 5 b ger€orming the <br /> following work description of work) : <br /> c , G0De+-►• <br /> 't <br /> Work ,will commence on or about for approximately <br /> r :v <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 rules, regulations of San Joaquin County and subject to <br /> inection and ap roval. <br /> 4ature <br /> of Applicant - Title � _ <br /> 't? L�`tJttou4smvm�`�t 1� �-� Date <br /> MASTRR.PS\FBSSCBDL (6/00) <br /> i <br />