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i 7 7 <br /> APPIUCAEON FOR ENCR®ACHMEMT PERNT <br /> PLEASE PRINT: <br /> Date /lJ-z 7 - 2 D!S OFFICE USE ONLY <br /> To: San Joaquin County JOB it ( ,;j ] REF# <br /> Department of Public Works APN CR# <br /> �j~�� P,�►�► 3 ��2.Z �� EXP.DATE <br /> VALID . l- '?6r1'5'-T0 :1-IS-2616 DRIVEWAYS: <br /> (Applicant Name) STREET � ( • } <br /> AREA QUAD <br /> TYPE u <br /> (Mailing Address) FORDS 5 U `ZG <br /> At NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> C <br /> Pew <br /> Oe,eID lase pate, <br /> (rAt(OA eo <br /> � 5, 6• <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way�n <br /> the W side of E approximately o, A- fee i e <br /> Of��,4,n p 2& L r n pn _,by performing the following work(description of work): <br /> Work will commence on or about J I- 2- 1 S" _for approximately_ l O 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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> �/9 _ -'a v f <br /> Signature of Applicant-Title Date <br /> 61JCEMALSERNCEMCLERICALWUMV.WKCAASTER.PSIS4CROACHW,EIJTPERV,,FrAPPLICATION.000(0.113) <br />