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APPLICAEON FOR EXROACHMENT PERNT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# (Jy S Z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> �IG VALID ` _ TO! DRIVEWAYS: <br /> (Applicant Name) STREET (a1y P 1 (-r <br /> ee '' AREA CUAD _ <br /> TYPE MalhtlCvt �a���a�� <br /> (Mailing Address) FORDS s s w�✓ 2 b <br /> q NOTES <br /> (City,State, Zip Code) <br /> gby-3/6' 17 G7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 7T 5 <br /> The undersigned hereby applies fpgr permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Al i S side of <S"e_Il !T^ approximately AQ\ /mileV/451- <br /> of Alt) S-t . 5 f by performing the following work(description of work): <br /> it e ptG G e- TJIG V�L4IF� � C1.'A-�l ICS mw. Cw► t✓ C IQc 4 V'c k .s <br /> Work will commence on or about for approximately. days. <br /> I,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 a n accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> I e of Applicant'-Title Date <br /> 6i:ICENiRALSERVICESICLERICALIPUBSV.V�nVdASTER.PSIENCROACHf/ENTPERfdRAPPLICATION.00C(OJ13) <br />