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I <br /> APPS.-0CATIOM FOR EMCROACHMEMT PERM - <br /> V, •.� � ;�i V t1 h.] <br /> PLEASE PRINT: <br /> Date �/® m-7- e e 1 S- OFFICE USE ONLY <br /> To: San Joaquin County JOB# S Z . REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> ��� 31 1 •?� SS VALID . TO 3 /- ( (� DRIVEWAYS: <br /> (Applicarit NarneT STREET W <br /> AREA QUAD - <br /> 4l� �'(� U) a-vi e— TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> L' <br /> (City,S ate,Zip Code) <br /> �reaCode tliprhone P er�—�_ <br /> Sket Detailed plans may be submi e <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S side of Ga M,r! A e( approximately -.W 47bmila )E _ <br /> Of. M p 16 1 e - r '44q toA ,by performing the following work escdption of work): <br /> Work will commence on or about __1 1- Z- 1,9- for approximately / 20 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 /> Signature of Applicant-Title Date <br /> 6CICEMRA(SERVICESICLEFICALUIUM.WKL'iASTERPSeJCROACW,ERTPERNRAPPLICATIOR.DDC(09113) <br />