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r APDL ZION FOR ENCROACHMF 'T PERMIT <br /> ..o <br /> PLEASE PRINT: <br /> oMCE USE ONLY <br /> Date / JOB #^ //oar REF# G'� 2 7 <br /> APN a So - Ua -/6 ,17 CRV# <br /> To: San Joaquin County Highway-Department. EXP. DATE s uv DRIVEWAYS; <br /> // VALID �/ vD TO !rte / <br /> e-- �� J6 - �.� r.sl O ? STREET �L.EV ENTff J T *,�---- <br /> (Applican Name) AREA 71..4 QUAD tet/ <br /> TYPE <br /> FORMS (SSI-W(A1 <br /> (hIailing Address) NOTE <br /> ( Ity, State Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pians rzay be submitted) <br /> 1i VVFTI—P) <br /> AN <br /> TH <br /> L r.AL <br /> The undersigned hereby applies for permission to excavate. Qonstruct and/or otherwise encroach on County <br /> // t� <br /> Highway Right-of-Way on the ruo/Z77f side of -15 - approximately, .S ,by Performing the <br /> feet if T of le-1S-Af <br /> folio ork: (description of work): ` <br /> Work will commence on or about <br /> leer 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 <br /> agree to do the work described above in accordance with the rules, regulations-of San.1oaqu�.n County and subject <br /> to inspection and approval. <br /> SIGNATURE OF APPLICANT - TITLE DATE <br />