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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRIN 1: <br /> Date /0 0 +� OFFICE USE ONLY <br /> To-, San Joaquin County JOB# ,OCC6- REF# <br /> Department of Public Works APN CR# <br /> / EXP.DATE ,- ��• t• O R <br /> /3�1�C�1. CAnf7/bt�-1�rr,� VALID t0 • tS.O$ TO _..�IL I. DRIVEWAYS. <br /> Applicant Name) sTREET Ste" �, ECL Ir •_ <br /> AREA `-ir4id _ QUAD <br /> X031 w1�fG� <br /> 4, 110 TYPE �5d 4"'C 1!1Vr►h/ <br /> (Mailing Address) FORMS 5s �; --- <br /> NOTr g <br /> (City,State,Zip Code) >a <br /> (Area Code-Telephone Number) otJ cTlotJ <br /> Sketch(Detailed plans may be submitted) <br /> 5C,e,. G 4 L�G✓� dt'G c✓ ' <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the, side of approximately— faetlmile of _ —,_ .—,—,by performing the following work(description of work): <br /> Work will commence on or about S' _ for approximately�LL) _days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> !�M^ faro <br /> /01 �J/4�" <br /> Signature of Applicant-Tdle <br /> 'J pate <br /> E;AR.9V.'NOiARTENVgIFW-*C VACM61ENfffRMRAFMUCATWNU�' (010.w) <br /> Zd W&'-T:?T 900E 60 ';0o 926Z8Zb60E: 'ON XHA NOIlMdi NOD HOU19: W06A <br />