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C L,tI <br /> APPLICATION FOR ENCROAC HENT PERMIT <br /> PLEASE PRINT: <br /> Date /6 e " OFFICE USE ONLY <br /> To: San Joaquin County JOB# 31(fsZ REF it <br /> p JDepartment of Public Works APN CR# <br /> EXP.DATE 3- - <br /> VALID TO �- - DRIVEWAYS: <br /> (Applicant Name) STREET } <br /> AREA (�f�y� TO <br /> f <br /> s+ L et 14 TYPE —` <br /> (Mailing Address) FORMS _�j <br /> NOTES <br /> s f6�k�-o�► CA <br /> (City, tate,Zip C®de) <br /> (Area Code-Telephone Number) <br /> Sketch Detailed plans may be submitted <br /> The undersigned hereby applies or permission to excav te,construct and/or otherwise encroach on County HighwayRight-of-Way on <br /> the Vel side of X 0 bp��s �Q� approximately '4200 l eet7mile .S <br /> of %A kr W ,---fl, , by performing the following work(description of work): <br /> Work will commence on or about /dam — 15- for approximately days. <br /> I,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 /> 6LICENTRALSERVICESICUUUCALIPUM.WKWASTERPS04CROACEN!EWTPERN,RAPPLICATIOIaAOC(4.113) <br />