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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (5 O�{pj� OFFICE USE ONLY <br /> To: San Joaquin County JOB# ,//�►jf, , REF# — c5` s 3 o <br /> Department of Public Works APN CR# C, <br /> EXP.DATE j/•�e.pg <br /> fir, Skc.�o►nP( VALID TO /!•/•d$ DRIVEWAYS: <br /> (Applicant Name) STREETj,�— �y J <br /> AREA QUAD x <br /> TYPE <br /> (Mailing Address) FORMS <br /> _bGkEc.n� CIA 24612 NOTES <br /> (City,State,Zip Code) <br /> S co- ass- 2?YS6 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> —$e 2r 4(a 4 Plw"` <br /> A ----yZ <br /> MS � wi�P �r��t•� , - _ _ _ _ _ _ _ <br /> Rcp`rt /ave,u.c. � <br /> A <br /> t <br /> x x x <br /> OK— x <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_ �_�-t- side of Ate approximately 10o_ � , feet ife so � <br /> :!M4 �"� n.c. ,,by performing the following work(description of work): <br /> Seenngl �ftrrx f,c1n+ C ERJ ! <br /> I <br /> rn ♦i f� '+ II <br /> Work will commence on or about ms's t�c;t � rr 7.��Sc for a <br /> pproximately days. <br /> I,the undersigned,certify that 1 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 /> Sign ure of Appli nt-Title Lis 1 lU �i1S <br /> Date <br /> E'.PDG.SY YAOA{A,¢SE.^.95"ENCRpRC}1 EWPEPWTAM 11AT-,AN DOC(OV031 <br />