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APPLMATION'FOR:ENC .AC -PST <br /> PLEASE PRINT; <br /> Date ' �- � <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# // REF <br /> Department of Public Works App <br /> CR# <br /> L w��_pEXP.DATE <br /> C SS �i 1 7�C?:- t,, VALID <br /> (Applicant Name) STREET ! DRIVEWAYS: <br /> ��J"': <br /> AREA i!/ QUAD <br /> (MailingAddress FOR <br /> MS <br /> NOTES <br /> (City,State,Zip Code) 7,� ©.,Mon z 0 Alt <br /> Vice-�kr2t <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may bs submitted) <br /> 1-0 <br /> 1E. t'hiv�1 2�o <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise ercroach on County <br /> the �;c tZ�'7.-� side of <br /> t- Way on <br /> of approximately t0hnite <br /> byam lierfomfmg the'fdbwing work(d on off�w/o/rk,. <br /> Work will commence on or about <br /> for approximatelyr days <br /> I,the undersigned,certify that I am the owner of the respective pro <br /> work described above in accordance with the rules and regulations of San oram <br /> Countuafffied y and subject <br /> t to�and agree to do the <br /> Peron and appfoval. <br /> d M •f <br /> LlSignature of pple � <br /> Date <br /> E.VPUB-SVWKWk';TER.PSIENCROACHMENT PERMITAPPCICATION.DOC (01=) <br />