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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> - <br /> Date r> �c> -OZ ppB OFFICE USE ONLY <br /> To: San Joaquin County JOB #_73(oi / ! REF # <br /> Department of Public Works APN p CR' # <br /> EXP. DATE 94-69 <br /> / VALID To C7 DRIVEWAYS: <br /> (Applicant Name) STREET 41-E.4',gwgm (-A)A�/ <br /> AREA �iTdc�Ysl� QUAD <br /> � LGA <br /> /`f43 �6%4JP1b0A-7 TYPE <br /> (Mailing Address) FORMS -2 <br /> NOTE <br /> (City, State, Zip Code) <br /> �0 5 SL-7/ ?' <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 7Z <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> o erwise encroach n County Highway Right-of-Way on the Bp side of <br /> &, approximately feet/mile <br /> of , by performing the <br /> following work <br /> // (description of work) :�j�4fi,//a/!G ,� •S�4�B M t✓ <br /> `,CarYt,�J t�lT 5/c •ov!CnGXctHcll^tGc��four / "X 602-0lc/L-fP iDccrj� �/Z'HC <br /> /r1 <br /> 45',7-h In Puc D/ "PC roM AeA V 506 4n f� A)6c,1-l/�TT- ?o[lh �/er oAG C fj✓�t7�-f <br /> ��� •�X ., bac r �� � 04 r- c c Z")( ^' / 'fil„c,(c <br /> Tz'n'/e-1i JF O/Are- Y- / 4c.b I fyLe, Q <br /> Work will 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 tze 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 Date v <br /> MAS':EF..FSIFEHSCFSL (5/M <br />