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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: , <br /> pate <br /> © OFFICE USE ONLY <br /> To San Joaquin County JOB bb REF # <br /> Department of Public Works APN CR <br /> EXP DATE S/i~61 <br /> 7 e efS VALID ` —PO/ TO DRYVZWAYS- <br /> (Applicant ame) STREET 44«floAl AvE tr <br /> AREA s$70oC;T-e QUAD Cc- <br /> w S� i97�� _„ TYPE �Lt cN f�d R ��el Gi G�/�ZL ¢ <br /> (Mailing Addreon) FORMS 557,/k/ <br /> NOTE <br /> Gt/Do _ y r l' 7- - <br /> (City, ate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> c5ce <br /> ;s Seo y 9 <br /> The undersigned hereby applies for permission to excavate, const t and/or <br /> otherwise encroach on County Highway Right-of-Way on the � E side of <br /> -A22"S5','O-'7 vL approximately /-Ceemile <br /> of T/12 SGcJ Cis/�/2r o Il7,S�io - b performinS the <br /> following work (description of work) ✓. <br /> G -2-o Jae <br /> .e oo� <br /> :ss ' <br /> Work will commence on orabou or approximately <br /> days <br /> I. the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> SigAet a of App icant - Ti. a Da e <br /> t'At'Uk PSNFRESC=L (6/30/001 <br />