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APPLICATION FOR ENCROACEaUM" PFRI 1T <br /> s <br /> PLEASE PRINT: RECEIVED <br /> Date /'i. �� . .�itJU(gip 20 <br /> Wj <br /> To: San Joaquin County JOB # �• _( F � i F�J,i i�S <br /> Department of Publj.0 Works APN CR ## <br /> 36 LIf Q �- EXP DATE <br /> Ole <br /> VALID TO O 'DRIVEWAYS: <br /> (Applicant Name) <br /> STREET <br /> AREA - - QUAD 'y <br /> TYPE OLE GOCATID�J <br /> (Mailing <br /> /Address)S �/' FORMS 9-, NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone. Number) <br /> Sketch (Detailed plans may be submitted). <br /> �.#c. c P <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on Cou=nty Highway Right-of-Way on-the 510S4A_ side -of <br /> v ive r approximately feed-mile E 4S-� <br /> of _ 'Tl+n/N fui� 11v by performing the <br /> following work (description of 'work).: 1.1 / <br /> r Le. C 4rx <br /> O <br /> Work '11 commence on or about for 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 /> Signature of Applicant— Title <br /> Date <br /> RETURN PERMITS TO: <br /> JOB PROCESSING DESK, BLD 14 1� 3 y <br /> 4040 West Lane <br /> Stockton, CA 95204 <br />