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APPLICATION FOR 'ENCROACE74ENT PERMIT <br /> PLEASE PRINTS • <br /> Date J A ODQC <br /> OFFICR USX ONLY <br /> TO: San Joaquin County JOB <br /> Department of Public Works APN REF # <br /> CR # <br /> EXP: DATE <br /> VALID TO =��Q/i 4 DRIVNwaYs= <br /> (Applicant Name) STREET <br /> � <br /> / AREA <br /> a 3 D c) C C( H� v" yx 1`6 TYPE QUAD <br /> (Mailing Address) FORMS <br /> •V G(z* �t >a 10 <br /> NOTE <br /> (City, Stat*, Zip Coda) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> c-�T 92. <br /> -Tce <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the <br /> of ayq + �q approximately j side of <br /> —_r f 9,064 N feet/m4+w 'L IQ T <br /> following work (description of work) : o ✓, �~ S by performing the <br /> OF i - - c� �.� C�jtvDu i'�- if-T c i� G _ 5C <br /> ['-z�v nu 1-1 F1 C 2--A C <br /> Mork will commence Qa-a*--abs jA ;v k, T �C, )q <br /> days. i �uL� I^e Ise 2�/4 for approximately <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> OW <br /> gi ature of Applicant - Titla — <br /> Date <br /> 'As•=3A <br />