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A -PA A T ION FOR ENCROACHMAT PEEMiT <br />PLEASE PRINT: <br />Date <br />9' <br />To: San Joaquin County highway Department. <br />(Applicant Name) <br />/S'1 b6r14&L0 Ad9 <br />(N ailing Address) <br />d-4 ,5-o3 S <br />(City, State Zip Code) <br />Ll /'P <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submittecl) <br />r5-0-1�-5u) <br />OFFICE USE ONLY <br />JOB #- 1I00'S REF# _ <br />,PN - - CRV#� <br />EXP. DATE `/ <br />VALIL>�,`�,y_q SS TO _ <br />STREET CID rrd k G V u) _MP <br />AREA QUAD 50 <br />TYPE _ ' G� c C= - , , %� <br />FORMS <br />I NOTE <br />The undersigned hereby applies for pe ssion to excavate, <br />Highway Ria -of-Wayon Of <br />' � side of C <br />feet 1milaof L of <br />following wor : (description of Nvork ): t <br />DRIVEWAYS: <br />or otherr se encroach on County <br />, bl, performing the <br />Work will commence on or about 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 approval. <br />SIGNATUREWF APPLICANT -TITLE DATE <br />