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APPLICATION FOR EMCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works _ 73ao REF <br /> APN CR# <br /> EXP.DATE _ 1 IS_ <br /> VALID i!O 1 t� TO 1 1's DRIVEWAYS: <br /> (A�D�Bllcant Marne) STREET ''L`25E1/ �✓� <br /> L/6 LI0 LIIISI /'(� AREA 5-T�fj _ QUAD "14S <br /> TYPE , <br /> (IVlaelgrag Address) FORMS S-5-WWF--fig TC/lc�i C.e.�i� a <br /> NOTES <br /> (Clty,State,Zip Code) <br /> 3/(- -+ 767 <br /> (Area Code-TetePho€ae I1ltarrafaeP) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate <br /> the �Aa-�. side of , construct and/or otherwise encroach on County Highway Right-of-Way on <br /> S '�Cv-c.e, �Cju,� <br /> of&. ��c�u-� `aAPM*r"tely b �1.� ,*�,,� feet/mile <br /> ''—" y performing the following work(description of work): <br /> r <br /> Lt <br /> Work will commence on or about <br /> for approximately days. <br /> 1, 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> . . I I &� — /6 A// �— <br /> Si PPlicaot-Title - - <br /> Date <br /> I.ICEHiRALSERU4CESlCLERICAL1PUB-SV.I%'Kl'.'ASTFR.PSOICROACHNENTPERI.!FFAPPLICAiION.COC(09113) <br />