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APPLICATION€ FOR ENCIROA.CHMENT PERMIT <br /> PLEASE PRINT. <br /> Date <br /> OFFICE USE ONLY <br /> lo: San Joaquin County JOB tF <br /> Department of Public WorksS REF# <br /> APN <br /> EXP.DATE OR <br /> # <br /> �' .�L L✓ �G G G�UGr�,,��;(� —l -1 <br /> VALID J — /of_/ TO I <br /> STREET 5 t —1j:- 16 DRIVEWAYS: <br /> P <br /> (APp scant Flare) <br /> AREA QUAD <br /> _ TYPE .� -- - <br /> Walling Address) FORMS S <br /> NOTES <br /> State,Zip Code) - - <br /> (Area.Code-Telephone Mumber) <br /> Sketch etailed pians may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hi way Right-of-Way <br /> the � side of_�rA�'L/,/ r Y 9 Y on <br /> of r�i�,►t OG' �$- 2 .approximately J, c, fieet/mileL� <br /> by performing the following work(description of work): <br /> Work will commence on or abouf <br /> - i- for approximately Z days. <br /> I,the undersigned, certify that I am the owner of the respective property, <br /> agree to do <br /> work described above in accordance with the rules and regulations of San Joaquin qualified <br /> nd subject toto reesent the o spect ownerdpn and a oval.e <br /> PP <br /> Signature o"-Title / <br /> Date - <br /> 61:10E I ISEFMCESICBICAL)PUBSV-WK""ASTELPSE2,CROACH;iEIJTPERrdfTAPPLICA710N.00C(09/q <br /> 1 <br />