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v= <br /> SCS` <br /> APPAATION FOR ENCROACHM*T PERIMiIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date Ili-�-��_ >=� JOB H 7,;� D 77 REFH <br /> APN -_ - CRV4 <br /> To: San Joaquin County Highway Department. Exp• DATE / Z 1 v SJ <br /> VALID o 9s O DRIVEWAYS: <br /> STREET <br /> (Applicant Name) AREA QUAD sE ' <br /> TYPE��J/e 6- <br /> 0. L �P/�Ol -!57- FORMS s 51w 4--Z-29 <br /> (Nlailing Address) NOTE <br /> (City, State Zip Code) <br /> f�OV/lir SS- -9, <br /> (Area Code-Telephone Number) f1f�"Llewx/O/V/Jn'. <br /> Sketch(Detailed plans may be submit',4 ,fCe 77 if/o_ eel --C�/ UO y„ <br /> C) <br /> rn <br /> �I v <br /> cn <br /> a <br /> IND LCSTRML <br /> m <br /> U <br /> The undersigned hereby applies for permission to excavate,construct?ec /or o erwise encroach on County <br /> Highway Rim t-Of--Way la � approximately <br /> IInle Of � � , n ,by perfOrmwg the <br /> following wo : (description of work): �� c i ir�r <br /> ® /��_ -- <br /> Work will commence on or about /Dr for approximately 3 0 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 d approval. <br /> ay s <br /> SIGNA OF APPLICANT - TITLE ,. DATE <br />