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v <br /> APPLICATION FOR EMCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> Date/ OFFICE USE ONLY <br /> To: San Joaquin County FEXP.DATE <br /> REFDepartment of Public Works CR# <br /> IS- TO li , �s DRIVEWAYS: <br /> (ApptrCant tVara9e) <br /> 'y6'10 <br /> �PS�` ' AREA <br /> dV GA7W OuAD <br /> TYPE A5 Pq 1&. r�pw t <br /> (Mailing Address) NFORMS <br /> OTES 1=1/1A a� <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> S7 <br /> (Detailed plans may be submitted) <br /> w� OLAi evJ_,,-(11 1 <br /> LeGtc- �('c,i✓ <br /> The undersigned hereby applies for permission to excavate construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the (— side of approximately_ 4l7 Z +'mile /(�ov�C, <br /> of_ S I' <br /> W X 5 /-s S1 - by performing the following work(description of work): <br /> Work will commence on or about 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 a n accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> eK�-� I/II// - <br /> r e of Applicant-Title Bate <br /> C,I ICLNTf2Al.SEkU10ES`,CLFFICALIFUfI-SV.Y:'i:UMSiER.pSiGdCROACH:.%EWT PERI.iR AFPLIGATIOIJ.�OG (0 iq <br />