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APPLICATION FOR ENCR®AC HENT PERMIT <br /> PLEASE PRINT: <br /> _q _ A <br /> Date v.z-43 C.��L.� ;, • ��1 " r' OFFICE USE ONLY <br /> t <br /> To: San Joaquin County JOB# 7 300 77 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE S" <br /> C t-1 r=•c)2/u i A W/9!_ER. � I [ VALID TO -I S(Applrcant Name) �� - SDRIVEWAYS: <br /> STREET W/P 6 S ffr <br /> 1 6 O a . 1,19F- _ AREA � o QUAD C <br /> TT f- S-T- TYPE <br /> (FailingAddress) FORMS S / 1.41 <br /> / <br /> - STO L Y- Q N/ � `7 5a- NOTES <br /> (City,State,Zip Code) <br /> (Brea Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right of-Wa on <br /> the c u f side of LU 1 4;t� approximately mile ► '3 <br /> of F� , f; ,by performing the following work-1 cription of work): <br /> <rt <br /> Ic a-15 <br /> A t <br /> Oct 117 2�), — .! <br /> Work will commence on or about - 1 _fora pro imat 1 _ 1�l7 <br /> days. <br /> 5 t r <br /> 1,the undersigned,certify that I am the owner of the respective property,or am quell led t re res t the owner and agree to do the- <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant e Title I Ute <br /> M::ICENMALSSUCESICLEPJCALIPUSSV.WFVAASTERPSVTCROACHME14TPERh11TAPPIJCATIOROOC(59713) <br /> 1 <br />