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209-433-3990 P. <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date --- 4 -Q ll— C7� _. <br /> T OFFICE l,'SE CNLY <br /> To: San Joaquin county JOB <br /> Department of Public voforks REF# i <br /> &:i I,, H s C/, APN CR <br /> (,eoes, S �nIZIF,n C �2fo{ee(vprne,rf LtC EXP.DATE -- - - -I <br /> VALID TO <br /> (Applicant Name) SDRIVEWAYS: <br /> TREET <br /> 3�1 e5S t2va�,d AREA QUAD _ •-- — <br /> ._.___.._____—_-�`_ <br /> (Mailing TYPE Address} , FORMS <br /> c,4 Cl S 3(06 NOTES <br /> - --------- <br /> (City,State, Zip Code) <br /> (Area Code-Telephone Numberj T <br /> Sketch(Oetailea pians may ce scbmitec) —_ <br /> I <br /> .4#zz,hP of <br /> The unders;gned hereby apples for permission to excavate,co struct and(or otherwise encroach on County Highw Right-of-Way on <br /> the 41 , , <br /> - __________side of <br /> of approximately /'l() e mi>e �f- <br /> _ by performing the following work{ escription of v6,orky <br /> Cts So u�ncY ar..rrc`q./ec �?.� 'trr+ lO,�j n/t r•. <br /> R�c,,,ton a r l�t1 r <br /> bVork nrill con•men4 EVA 0_z <br /> ce or or abou,;.�_��"v/ /j .2 pD& - --- <br /> far approximately anQ days. <br /> I, :le undersig-ied,certify that I am the ovmer of the respective property,or am qualified to represent the owne ar.d agree to doe <br /> work descrbed above n accordance with the rules and regulations of San Joaquin County and subject to inspection and appro:+al. <br /> Signature of Applicant-Title <br /> Date <br /> ".SR1S1 MrttlM:'EF°`i'cGFO/..:YVB:1 FtiW:i?°MII:Agrt OOC,•.FW) <br />