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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date p OFFICE USE ONLY <br /> To: Sart Joaquin County JOB# A 6 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE� _ 2 I 0$VALID , o TO z 0 a$ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAGw - QUAD <br /> "gess) <br /> 1� Z!7 TYPE{MFORMS . <br /> NOTES <br /> (City,State,Zip Code) <br /> �ioq -2 q-y - 4tp4-o <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) - <br /> S>re- PLA04'., of,: <br /> •oRTHVtL Rp. <br /> � o <br /> Z 1 <br /> J <br /> H w y' M0 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway R' ht-of W <br /> the side ofay on <br /> t�IN iGp, <br /> Of 11�"IAJ& approximately j fee i . <br /> by performing the following work(description of work); <br /> 4n L_.P. o f- 4Z,, ca=r lc)tj C.¢��.�,..�,r s�►T >z¢s:��h-fin.! <br /> Work will commence on or about for approximately. Z-1 <br /> days. <br /> I,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 /> . of M a y a �►�- t o 24-�o g <br /> Signature of Applicant-Title —�— Date <br /> El 13-R1WKwASfERP51ENCR0YOWRr AERWTAPPUUtION DOC(UtA7B) <br />