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APPLICATION FOR ENCROACHMINT PERIYHT <br />PLEASE PRINT: <br />Date 7 -�Ll -5-- <br />To: <br />To: San Joaquin County Highway Department. <br />jx1% S c 1M ° X17 <br />(Applicant Name) <br />(M:aWng Address) <br />s <br />C, d,1-- d,1 9sQ,0-C, <br />zip Calc) <br />�z <br />( - Tcle hone unrl�er ) <br />09> <br />OFFICE USE ONLY <br />JOB ft REFH <br />APN - - CRV# /a 7 /_ <br />EXP. DATE <br />VALID O RIVE WAYS: <br />STREE 1t/i.tsr �f SJR <br />AREA �. .� 1 QUAD <br />TYPF:���.-� <br />FORZvZS 3 . ..J c)-� = Z�— <br />NOTE <br />Sketch (Detailed plans may be submitted) <br />L� <br />m <br />(k The undersigned hereby applies for permission to excavate, construct and / or otherwise encroach on County <br />Highway Ria t -of -Way on the.Aio,e7// side of approximately <br />6,C,6tmile c`�— of ' 8 , s T, , , by performing the <br />following work: (description of work): 7,-Z v C/-/ 3ir-w 6 A—' <br />Work will continence on or about <br />S for approximately , U 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 will the rules, regulations of San Joaquin County and subject <br />to inspection and approval. <br />vh S <br />SIGNATU'2E OF APPLICANT - TEME DATE <br />