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APPLIO TION FOR ENCROACHM10 IPER_ MITA <br /> PLEASE PRINT: / <br /> OFFICE USE ONLY <br /> Date `Z.- 2., °l JOB # 7 3 0 REF# <br /> IAPN - - CRV# <br /> To: San Joaquin County Highway Department. EXP. DATE / Z <br /> VALID T DRIVEWAYS: <br /> P� E QTTEN: ��?OK'GP_ ole.YmO STREET /sJ�aov s /z6,�ros <br /> (Applicant flame) L AREA QUAD s <br /> ?,4 , 2, X 93 0 TYPE— <br /> FORMS 5s w �l <br /> (Mailing Address) NOTE <br /> (City, State zip Code) <br /> 20 2- 1 <br /> ode-Telephone N ber) ' <br /> Sketch(Detailed pians may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County <br /> Hlighway Right-of-Way on the side of approximately <br /> feet /mile of ,by perfo=ing the <br /> following work: (description of work): <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 /> �-nT <br /> GNATL OF APPLICANT - TIME I <br /> DAM <br />