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v <br /> v DL� MIXT <br /> APPLICATION FOR ENCNCRO C NT <br /> PLEASE PRINT: <br /> Date OCT 2 92004 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7REF # <br /> Department of Public Works APN CR # <br /> / ,., <br /> EXP. DATE 2' 2�• o'-f <br /> 6 . E . VGA 1 VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET SAMMOM Rd* <br /> AREA QUAD A Y1� <br /> i 1r TYPE FSR$ -t 'TW4H4# <br /> (Mailing Address) FORMS S lwvj 29 <br /> 0 r� NOTE 0q-Ztii-4W <br /> (City, State, Zip Code) <br /> { ea Code - Telephone N er) <br /> M <br /> Sketch (Detailed plans may be s mitted) <br /> 0 0 0 <br /> >rri <br /> S <br /> A-FALAAau �kejezo <br /> l + 00 <br /> n� <br /> j 0�D <br /> C <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> of by pe fo in the <br /> lowing work (description of work D <br /> �.�.. NAFY AE554Q. <br /> 4L Jae cbAle "51&4 <br /> AUJD 4>4CSV 12ffAI444U <br /> W wi commence on or about for approximately <br /> days. <br /> I, e undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> riec ion and ap roval. <br /> Q <br /> S'gnature ofis. ; - Title� Dat <br /> MASTER.PS\PEES®L (6/00) ����GG.• -- <br />