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APPLICATION FOR ENCROACMdENT PERMIT <br /> PLEASE PRINT: 1 <br /> Date P� 1�lI orris 5 YJSE ONLY <br /> To: San Joaquin County TSQB # REF # <br /> Department of Public works Apt? CR' # <br /> �^ - EXP. DATE (1-170F <br /> LiQot)\1 `Qnwfss /0� D)S�tU VALID To - ( -ZOO) anlv$wAYs: <br /> (Applicant Name) STREET _ h <br /> 1-IJ Z S l -1,7 2 AREA LiNAIn omm 111 F <br /> TYPE [SST, D2\Vc- <br /> (Railing Address) FORMS —,L) <br /> I <br /> Q7 <br /> r 2 3/P NOTE <br /> (City, State, Zip 'Code) � <br /> 1 Cc�B^7 - (D <br /> c <br /> (Area Code - Telephone Number) <br /> sketch (Detailed plana may be submitted) <br /> s., z_' Ll <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise energach on County Highway Right-of.-Way on the of <br /> approximatelyfeet/mile, <br /> of , by I performingchs <br /> following workdescription of work) : Gt-J 1 <br /> I U 'FI( a cwt S --V—O,A <br /> L-0EA-( - <br /> Work w ll co ce on or about for approximately <br /> on <br /> O1Jday.. <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 /> 17��uEn tIJC�I�ICt� ( y JC t� <br /> gnature of Applicant - Title Date <br /> 14iTRR,HS\HYl{:!C}mL lu/001 <br /> 7a/TM 'Intra C�I TwAgA n'it's bZE689b60Z 8Z:bi 800Z/60/00 <br />