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APPLICATION FOR BSCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB 1616V REF 9 <br /> Department of Public Works VA�P N <br /> JCR# <br /> <: EXP.DATE lc_ VALID <br /> (Applicant 0 7- DRIVEWAYS: <br /> t Name) STREET <br /> AREA QUAD <br /> /_VS <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephorie Number) <br /> Sketch(Detailed plans may be sub <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County <br /> the side of Highway Right-of-VVay on <br /> , _L��!­; 7--' I -� /_/ -_��-i -e approximately '- Z/ 1 <br /> of I- - feet/mile. _Z,/ <br /> K4 C�' A-: /-��i j-J '�'F 4:-��' 7 '­? <br /> by performing the following work(description of work): <br /> h A) <br /> _W01"Will commence on or about for approximately <br /> days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described dove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant'-,Title <br /> Date <br /> E t'UB-SV,'VhVASTER PSEIICRC�ACW.SJT PERf.IfT A'PPLIGATJZ I M DOC(016)3) <br /> r-C, 15 <br />