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APPLICATION FO EMG ROACHMEN T PERMIT <br /> PLEASE PRINT: <br /> Date �y OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 7 3,I)a S'Z REF.4 <br /> Department of Public Works APN — CR# <br /> EXP.DATE -3 <br /> C <br /> &L4 l i Q VALID 1- DRIVEWAYS: <br /> (Applicant Harhe) STREET ( ' 6 <br /> _ _ AREA J'�� QUAD <br /> Co . 1- �1 ( F S 1 TYPE <br /> (Mailing Address) FORMS 5 5 Wtvl2 <br /> - ST CSL 1L l O N/ � NOTES <br /> (City,State,Zip Code) <br /> (Area Code-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-Way on <br /> the side of approximately feet/mile <br /> of ,by performing the following work(desdr pfion of work): <br /> t ElkkN <br /> ' 0006 3 2 � <br /> f _! <br /> Worts will commence on or about for appy xi Lely days. <br /> Y <br /> 1,the undersigned,certify that I am the owner of the respective property,or am q life. to re esent 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-Title 415)ate <br /> MICEMRALSEI-ACEaCLEPJCAL1PUa SV.WI L ASlELp51E&,CRoACHS1ENTPmirrA('pLICAnoNAOC(stq <br />