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APPLICATION FOR ENC ROACHME T PERMIT <br /> PLEASE PRINT: <br /> -� 23 2.-015- <br /> Date ��.1 t �i OFFICE USE ONLY <br /> r <br /> -1 San Joaquin County JOB# -z REF# <br /> Department of Public Works APN _ CR# <br /> _ EXP.DATE _ j� •r <br /> (f L)I Q,E VALID A.? O J�j-1-,�,y�' DRIVEWAYS: <br /> (Applicant NaMe) STREET <br /> AREA QUAD <br /> /60a L . li AF,9y, -7-1 ST TYPE <br /> (bailing Address) FORMS 5 <br /> NOTES w`�� g�li�+sl <br /> (City,State,Zip Code) <br /> ao�1 '� Li -- � � l <br /> (Area Code o Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> e <br /> e <br /> � G <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highw Right of-Way on <br /> the W F s r- side of 00 P li R tE S i-. approximately 2-� eef/ i[e N PT <br /> of �°"''G` by performing the following work escldilp of work): <br /> 151 nJ� s- <br /> _LIA-1N iePA-t g <br /> I 'x i - <br /> Work will commence on or about_ for approximately days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to represent 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 /> Signalure.of Applica it e Title Dat <br /> 'l�H(�-SHMCE51CLH2CAL1PU8�yWKUdASiER.PSIERCROACH97QITPERM1ATAf'PLiCA770NCOC(W(13} <br />