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- 'C .HL �'fii�' '•JHTE� PCi„i i=C FH`; fdL. 2094640195 Tun. 16 200"7' 1 :c=1iPM P <br /> APPLICATION FOR ENCROACMaNT PERMIT <br /> PLEASE PRINT_ b <br /> ?]ate OFFXCE USE ONLY <br /> :'o: San Joaquin County JQl3 #_ 7J?U<�7 L R'E'F # <br /> Department of Public Works APX CR # <br /> EXP. DATE ^d <br /> L��4� , .�1 � .f��' 'VALM --- ' TO —! _r DLMWJAYS: <br /> (Applicant Name) STREET s �• * _ <br /> 4. <br /> �C © 757 4*kM ARRA V) QYTAA <br /> Mailing Addrous) PORMS _L . <br /> NOTE <br /> {City, S tAte, •Zip Code) <br /> (Area Code Telephone number), <br /> Sketch, (Detailed plans maY be submitted) <br /> The undersigned hereby applies for permission to•excavate, construct and/or <br /> athexvise"e,ucroach on •Couaty,Xighway Right-of-way.oa•the ��aE `` •" �'ide;.i>f <br /> of ` z --- approximately <br /> r . • by ,performing the <br /> following work (description Of,Work) :' <br /> 4,« <br /> Ste' <br /> Work will commence on or,,about — 1` $t <br /> b o days` for approximately <br /> I, the 'uidersigned certify, that 2 am the owner' of the respective property, rix am <br /> qualified to represent the owner and agree to do the work described above In <br /> accordanne with the ruleF, regulat ons'of San Joaquin County and subject to <br /> inspection and approval. CS$���`d <br /> S3gmature of Applicant Title Tata <br /> KASTR.yL 1lII�GCim:. 16100) <br /> i <br />