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APPLICATION FOR ENCROACMMT PERMIT <br /> Data OPFXCB CCSB MY <br /> To.- San adaquin County aoB # 7307 REP # <br /> Department of public Works APN <br /> EXP. DATEAT�'cC� S�.E�y VALM LD-77 TO l`x"0'7 DR fRAXE s <br /> (Applicant Name) STREET 4VA2 <br /> .1550�1 •t��.�ONT Sfi �\�fJ ARS s?Z;c�QUAD <br /> TYPE w <br /> (Mailing Addxess) FOM <br /> S1 <br /> NOTE <br /> (City, state, .Zip Code) <br /> ao'�- XAVA-SS <br /> (Area Code - Telephone r�ber), <br /> sketch (Detailed �lans 'may be submitted) a <br /> m N tn <br /> • 0 .� ti <br /> r110 0 C, <br /> w z <br /> The undersigned hereby appiles for pexTai,esion to,excavate, construct and/or <br /> otherwise•encroach,on County.8ighway Right-o£-Way••on the side..of - <br /> approximately feet/mile <br /> of , ' .�. , by"Performing the <br /> following work (description of work) : <br /> Work will commence on or'about or approximately <br /> _too days., '� ' <br /> X, the undersigned certify that X am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work desoxibed above in , <br /> accordance with the rub , regulations'of Saxe Joaquin County and subject to <br /> inspection and approvalral 01'1 010 ' <br /> Signature of Applicant Title Date <br /> tas�.vslv�ra�L cc/ooy � •.., <br />