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0 <br /> APPLICATION FOR ENCROACHMENT PERMIT' <br /> PLEASE PRINT: <br /> Date OFFI EUSEONLY <br /> To: San Joaquin County JOB# 1 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE � t_2 <br /> /fx Sau-<e 4.1ao rn<. VALID 21-2<jtyTO 3-1-201u DRIVEWAYS: <br /> (Appricant Name) STREET vo 1S—T ` <br /> n AREA QUAD' — — <br /> 9 efoa.fn /<ol �� N TYPE <br /> Mailing Address) FORMS g <br /> NOTES <br /> Gass !/a//e• CLI 9/ <br /> (City,State,Zip Code) <br /> 530) 1�2-y2.ov <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �re 4 A<Xq <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway RI ht-of-Way on <br /> the s-p" A sideof PAC/nom/, /Io< d approximately_ /2 1 feet/rfi <br /> Of c Toa /z<! by performing the following work(description of work): <br /> 7L< r o/sf'e� u� nw to'/ / r alt /c //t<f/11o,, f so / A c( a aJ, <br /> ,nri koa -f ) / <br /> W le 4eG( /6 Al 14/i U 14 ,g <br /> Work will commence on or abouts// zroximate)v/Y for app2 days. <br /> ],the undersigned,certify that I am the owner of the <br /> nrespective property,or am qualified to represE nt 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 /> Signature of Applicant-Title Date <br /> NiLENRUISFAlAtE5lLL9UCKW&SVNMY41SiEA.PSIFJ1fN0AtXMEM 1+EAMTMftItAM)HOOL (013) <br />