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APPLICATION FOR RNCROACHMENT PERMIT <br /> PLEASE PRINTi <br /> Date e <br /> 1USN ONLY <br /> To: San Joaquin County JOB # QQ79 4 REF <br /> Department of Public Works ADN CR <br /> RXP D1 <br /> (Applicant Name) STRS�T �. DRIVSNAYB= <br /> AREA QUAD W <br /> TYPE <br /> (Nailing Addrexa) FORMS ; <br /> I. ?-:5a 11) Nara <br /> (City, State, Zip Code) <br /> (Area Code - Telephone M=ber) <br /> Etailed plans may be submitted) <br /> fee- rf to� � 6 s 4� 11'7- ZriP.fnr1,rA0- <br /> The undersigned hereby applies for permission to excavate; <br /> otherwise encroach on Ccunty Highway Right-of-Way oc netruct and/or <br /> n the Lv $, <br /> r`'(r <br /> of , approximately feet mile side5-of . . . . <br /> / <br /> following work (description of work): by performing the <br /> 7/t..e'i L <br /> Work will commence on or about A-/) <br /> 3 days, for approximately <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 /> inspection and approval. <br /> Signatur�Jppii--t t1a -�� <br /> Date <br /> Y/3^ii PSI 72LS'-F.7L iiir91 <br />