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APPLICATION FOR ENCROACHMENT PERMIT <br /> 8LWE PRINT <br /> Date _ "� OFFICE USE ONLY <br /> 7305 - Zo <br /> To- San Joaquin County JOB #Z6 PIE? <br /> Department of Public Works APN CR # <br /> ` Exp. DATE <br /> VALID -/ -a7 TO1 -%y I DRIVEWAYS: <br /> vvv (Applicant. Name) STREET ✓A2totar <br /> AREA 5 tae �s QUAD �LtJ <br /> (�1 veil' L� lJ Tv;)E -3 s <br /> ([ailing Add`xepe) FORMS <br /> NOTE <br /> p (city, Stater Zip code) <br /> 71- �K, I <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct axed/ox <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> G'RD7ti� /`9u rAC .3i/:j7:� approximatelyfoot/mile <br /> of by 'performin.g the <br /> following- work (description of work) : <br /> wor]� will commence on or about 67 for approximately <br /> X> day:a . <br /> 1, the undersigned certify that I am the owner of the respective property, or am <br /> c9lalified to represent the owner and agree to do the work described, above in <br /> accordance with the rules, rego-lations of San. Joaquin County and subject to <br /> J,nspecti. i and approval, <br /> rte' 5T//�2/4r 'l LJ J z L <br /> Si at-ure of Applicant - Title Date <br /> MA9TBR.P2\Fl�PFc�t fG/091 <br />