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APPUCAVOM FOR EMCROACHMEN U ISE' M11 u <br /> PLLASE PRINT, <br /> Date =�� _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# _ REF# <br /> Department of Public Worl(s APN CR <br /> y� EXP.DATE ��- <br /> G` ! 2 —7 10 VALID . �r - �� 0 It I !S` DRIVEWAYS: <br /> (Applicant Mame) STREET ztWy } <br /> AREA ! '0e&n'V QUAD <br /> ��® ��� 6�� �� ��� TYPE , E ,7Q1 5exp w,ge t� C2EQ�9i _ <br /> (!hailing Address) FORMS W 1 2� <br /> NOTES <br /> (Cit�p, ate, Zip Cede) - <br /> 0 -3 lo' 4 7 6 <br /> (area C®deo 6 ele�vP��ne�,��m��er� — <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excava e,co truce and/or otherwise encroach on County Flighag <br /> ight-of Way on <br /> of —�____.-_.____side of -7 1 (> v p� -a e approximately 2 3� ife S <br /> - ��®� ® ,by performing the followingwork <br /> ( escnption of wort(): <br /> &A Aj4, <br /> _for approximately days. <br /> I,the undersigned,certify that I am the owner of fhe respective property,or am qualified to represent fihe owner and agree to do <br /> work described above in accordance with the rules and regulations of <br /> all Joaquin County and subject to inspection and approval.the <br /> Sig <br /> nawre of A-pplicant a Title Date <br /> h1-CFFIIP,ALS[RVICES,CL[RICALIFl18-SV.1lril'.1511=R2SIF11CR0AC4Fl,Ef�T PER1.!I(ApPLICA iIOII.DOC(02/13) <br />