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APDL IGA[ON FOR,ENC ROACH'W1ENT PER MiT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Deparinent of Public Works APN <br /> ftXP.DATE <br /> ��_�__—__ VALID 2 / TO /® ` �5r' DRIVEWAYS: <br /> (Applicant Name) STREET k4iAll9N' f l'orf# . <br /> AREA :5roe-,P-" Al QUAD 6e-- <br /> � TYPE <br /> (lylalliingAddEess) FORMS <br /> - ���/t-�%�! C-�• ���.--- NOTES <br /> (Cifif, State,Zip Code) - — - <br /> zI s-%----jS--` <br /> (Area Code o Telephme Mumber) <br /> Sketch(Detailed plans may be submitted) <br /> PZ- <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-of Way on <br /> the ji-- _side of // w <br /> approximately 0 <br /> of <br /> smile <br /> by performing the following work(description of work): <br /> c� /Vaz <br /> Work vdIli commence on or aboufi for approximately <br /> 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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature Of Applicant Q Title Date <br /> FA]CENRuSEK��CESIC�ICALIPU&SU VJIO1.i0.ST .p3�iCftOFCHR1EfiT PE�iF.11T APPLl0A7101dDOC(49/13) - <br />