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APPLICATION FOR ENCR <br /> OAC'nMNTPERMIT <br /> PLEASE PRINT- <br /> Date000. / <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB <br /> � <br /> Department of Public Works _ REF <br /> A <br /> PN CR #� EX-p. DATE <br /> VALID t •ll-D TO 2-1S-off DRIVEWAYS; <br /> (Applicant Name) STREET LSC: Ki tJlkt? A ki�r . <br /> �vyo cye s ,,� c AREA �C QUAD se <br /> TYPE -90PLe <br /> (Mailing Address) FORMS <br /> /aV nn ^^ <br /> fes, �./'f <br /> �' k�/ rZo Y NO'I'E <br /> (City, State, Zip code) <br /> (Area Code --Telephone Number} <br /> Sketch (Detailed plans may be submitted) <br /> S e e Cc. <br /> WOL, C.Lt <br /> Z v <br /> c) <br /> 3 x- 3 / 90 _ 0 <br /> " 1 � <br /> � _�, <br /> a X< <br /> OG <br /> x t7 <br /> C/) ! <br /> The undersigned hereby applies for permission to excavate, cons ruct d/or <br /> otherwise encroach on County Highway Right-of-Way on tl3e u <br /> �' s. ve / side of / <br /> approximately n0' feet Vie- '{fit We.3 t <br /> of �i2re .� �rG�tGLI <br /> follow�ri work (description of work)': [...t �� �/ ��e� �performing the <br /> , S r c <br /> Work will commence on or about /2 / / /�(p <br /> Cp(� days —�---/ for approximately. <br /> I, the undersigned certify that I am the owner of the respective <br /> propertyor <br /> qualified to represent the owner and agree to do the workdescribedaboverin am <br /> accordance with the rules, regulations of San ,Joaquin County and subject to <br /> inspection and approval. . <br /> Signature of Applicant - Title <br /> Date <br /> MASTER.PS%FMiS®L (6/00) . <br />