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r C0�j <br /> APPLITION FOR ENCROACHME PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date JOB# //00-1(, REF# <br /> ApN - - CRV# /0 7 2 4 7 <br /> To: San Joaquin County Highway Depaifiment. gyp.DATE 4¢7 W3— /yam <br /> CG�itJ Ts -- .SGS G �D VALIDTO DRIVEWAYS: <br /> STREET cZA .mo ,20 <br /> (Applicant Name) AREA L 0 QUAD A,E " <br /> TYPE CL <br /> ,Boo< s2 g FORMS 55 <br /> (Mailing Address) NOTE 9 ,4O CIL <br /> (City, Stattr 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 otherwise encroach on County <br /> 1-fig <br /> hway Right-of-Way on the side of aPPml3' <br /> feet /mile of ,by performing the <br /> following work: (description of work): Q9-40 CL /22' — <br /> 0 c i-' 7� / !� S S' /" 4 'o o A nv! o D ,NJ <br /> Work will commence on or about A i /-l9 �QOe 'Z/ s--for approximately / days. <br /> I the undersigned certify that I am the owner of the respective property,or am qualified to represent the owner and <br /> agree to do the work described above in accordance with the rules,regulations of San Joaquin County and subject <br /> to inspection and a proval. <br /> SIGN OF APPLICANT - TITLE X DATE <br />