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PLEASE PRINT: APP*ATION FOR ENCROACH&T PERMIT IT <br /> Date -3 OFFICE USE ONLY <br /> JOB # -73D-7:7— -� REF# <br /> To: San Joaquin County Highway Department. APN r " CRV# <br /> EXP. DATE S-6 97 <br /> �i�JFIL DELL VALID TO DRIVEWAYS: <br /> STREET f3�v, ,�i-6 oma. s <br /> (Applicant Name) AREA 77-114-0Y QUAQ5jJ <br /> h'�/ YDKu is TYPE_ <br /> FORMS S.S1 c�cti R- <br /> (MailirtgAddress) NOTE <br /> STor-kro%v CA. SsZo 7 <br /> (City, State Zip Code) <br /> 205 N1,V y7S11 <br /> (Area Code-TeIephone Number) <br /> Sketch (Detailed plans may be submitted <br /> 4 -54L6 A7-^TLNE.D -DRAvv1%G <br /> r IN 4G N ZALL%N&- 'PLEP�SE RE h`R TO -Toz UC: 3:575N\ <br /> UU 01 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County <br /> I-.lghway Right-of-Way on the W—_side of <br /> /Lo feet !mile S � <br /> nrg of STcaZnnAN �Q, appr°lamately <br /> following work: (description of work): ,N 4, y X y Ie s' s PL%�` ' r 1 ' the <br /> Is Lt P`T �� i f!✓!nl/r <br /> ASPHALT 4tim r?LAC.IN ( PvZ �JQIC D �tt,i Inc W I w2E' <br /> work will commence on or about for approximately days, <br /> I the undersismed c er fy that I am the owner of the respective property, or amed to <br /> quahfi represent the owner and <br /> agree to do the work described above in accordance with the rules,regulations of San Joaquin County and subject <br /> to inspection and approval. <br /> SIGNATURE. OF APPLICANT - TITLE <br /> DATE <br />