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APPLATION FOR ENCROACH PEFLINUT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date /-) JOB 9 -7 '3o 7-7 REF# A <br /> APN - - CRV# <br /> To: San Joaquin County Highway Department. EXP. DATE 3- 1 - 'Y(, <br /> /� VALID -a -fl-ro 3 -i_y6 DRIVEWAYS: <br /> STREET 8 S f # <br /> (Applicant Name) AREA S- c k--4r- QUAD -7-5 # <br /> �z-WW1'fOl ST TYPE- s Sery rc <br /> FORMS 5 51 wW; /Z—a <br /> (Mailing Address) NOTE <br /> 7-1IV l�� /�c"Zn Z <br /> (City, State Zip Code) <br /> (Area Code-Telephone Number) IV-1-Z1eW1-D/V/l6). <br /> Sketch(Detailed plans may be submitted) i9fL'77moo- <br /> F_Si if/o. <br /> h <br /> r <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County <br /> I-N.ighway Right-of-Way on the= side of ",C3 '` S� _approximately <br /> _ .�� ,by performing the <br /> feet /mile of �S <br /> following work: (description of work): <br /> 2 C6 e <br /> Work will commence on or about / - T- 9.5 for approximately Ito 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 /> SIGNATURE OF APPLICANT - TITLE• DATE <br />