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C:16� <br /> APPLY&ION FOR ENCROACHM KO PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> [JOB #__ �O Z_ REF# <br /> CRY# <br /> To: San Joaquin County FEShway Department. EXP. DATE 7 3 a f <br /> S2� llle/ 1� ZD, VALID o > TO DRIVEWAYS: <br /> STREET o,Ca <br /> (Applicant Name) AREA To QUAD 1� <br /> zLGY1e"fOl9 TYPE 7�eel-cl-I <br /> FORMS s�/w w ,2- z�_ <br /> (Mailing Address) NOTE �--7— <br /> STDC,�ToN z-4 95-2oa <br /> (City, State Zip Code) <br /> /-209- 0-644-81/l fI1�D/1, SS- 1 fJ <br /> (Area Code-TeIephone Number) i91/-L/0YT/0/V N. 7 5/'V <br /> Sketch(Detailed plans may be submitted) <br /> c� W <br /> 71 <br /> . , <br /> i C <br /> O r. <br /> c7 ) <br /> C= f T1 l <br /> M <br /> ' C L <br /> CA --{ <br /> 7: O <br /> The undersigned herebyapplies fo�r}�rmission to excavate construct and/or otherwise encroach on County <br /> Highway Right-of-Way on th �YV side of C� a approximately <br /> feet /mile of /'y ,by perfo the <br /> rming <br /> following work: (description of work S Ek!L <br /> Work will commence on or about Z -�yr - 9 5 for approximately days. <br /> I the undersi=ed 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 approval. <br /> c <br /> �TrT7 <br /> SIGNATL F APPLICA'�TI' E <br /> DATE <br />