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T <br /> APPLICATION FOR ENCROACIVIEI�T PERMIT <br /> PLEASE PRINT: <br /> ' <br /> Date OFFICE USE ONLY <br /> To: San Joaquin Count:y JOB REF <br /> Department of Public Works ZPN CR <br /> EXP_ DATE D 7 <br /> �sRln �T-�rcll VALID /nO�a T d DRIVEWAYS: <br /> (Applicant Name) STREET <br /> j r AREA ST,e e% QUAD <br /> �D lk&7:! 7- Le /� " TYP. µorgy r 6072E <br /> (Mailing Address) FORMSr <br /> NOTE <br /> 6r cl<r0A� /� sao <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> L r r-O > <br /> -4 CT <br /> aj <br /> c� <br /> The undersigned hereby applies for permission to excavate, construct Qd/df <br /> C <br /> otherwise encroach on County Highway Right-of-Way on the eCAST v� <br /> �si� � <br /> C1-CCPProxi.matelyI ' feet/mile'' <br /> of A.( by performing the <br /> following work (description of work) : <br /> 4/2 4fxZ-, !/,47-E Tho 4'x4`X4' ��s��cEs �OitiE yr-o�F <br /> _ C X/Sr�N� G s Sc e✓�C� i�`/C SEeo Ale) 7D /�!/Sl!ACL_ iC�EGC <br /> -S-57,f 11i e oS4S�f'•�/A GT <br /> 0 7/A f/�CE 727S✓7�/i'/E�2 Si24 Y G�/VE <br /> ork will commence on or about �� /� ?Coe, for approximately <br /> /02 Q 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 ru=':es,, regulations of San Joaquin .County and subject to <br /> inspection and approval: <br /> Date <br /> SZTatwe of _ra_NliCait Title RETURN PERMITS TO: <br /> MASTER.PS',,FEESC-mL (6/00) <br /> �oB PROCESS11V6DESK- BLD 1 <br /> 40401N�s!Lens <br /> STOCiCTON, CA 96204 <br />