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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# t e REF# <br /> Department of Public Works APN CR# <br /> _ EXP. DATE cL-/.5-2oi Z <br /> 74 Sowce, 6wcy, ?nc. VALID (-'2G2nL2TO $-/T Zp(Z DRIVEWAYS: <br /> (Applicant Name) STREET �_{m5k- <br /> AREA 1 C26 C QUAD S <br /> TYPE md'rl44ov-Iw.G tt-M �t&SFhUC#wv� <br /> ailing Address) FORMS <br /> NOTES <br /> —('City,State,Zip Code) <br /> (s70) 906- VP15 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Ste- Oyu a. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the w«-1 side of tfa, sVem-1 approximately 760 eedt/mile so-f4 <br /> of_/-/,41 A e.& /t by performing the following work(description of work): <br /> % / it. S ]eagun�'96z' l <br /> Work will commence on or about for approximately 3 days. <br /> I, the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> do - spa ��r..fiY! I;ZIA�i/ <br /> Signature of Applicant-Title Date <br /> E.WI ..WXIMLSIERPSENCRMCMENTPEWITVMP TWN.DM (010) <br />