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PLEASE PRINT: <br />Date; UiF--4nA_& <br />To: San Joaquin County <br />Department of Public Works <br />(Appiicant Name) <br />(Mailing Address) <br />(City, <br />APPLICATION FOR FI\!GK;OACHMEN I PFF.i'1111T <br />Zip Code) <br />(Area Code - Telephone Number <br />(Email Address) <br />)B# <br />APN It 123-Z11�4%7 <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />110065 REF # <br />CR# <br />_ <br />TO DRIVEWAYS: <br />_ <br />QUAD <br />�� Ske�fch (Detailed plans may be submitted) <br />� � 4 � o c�� � ap°� t+�v It�:!� <;''� �%CSR � �•�— y,�`/,+ <br />o �fl <br />eAaF <br />The undersigned hereby applies far permission to excavate, construct andlor otherwise encroach on County Highway Right -of --Way on <br />the . �%®_ 1��-t�► side of t! � � � � , `�1.� � � approximately feeflmile <br />Work vliill commence on or after <br />for approximately <br />days. <br />I, the undersigned, certify that 1 am the owner of the respective property, ar am qualified to represent ttre owner and agree to do the <br />work described above in accordance with the rules and regulations of San Joaquin Couniy and subject fio inspection and approval. <br />Signature <br />Y:IFCRMS & TEMPLATESIE'CRQACHMENT PERMIT APPLICATICN.doc (08108) <br />�,. 0 <br />Date <br />