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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: - <br /> Date t't'Df', 10 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ,//Dips REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Q <br /> L-►n&Ar,' 1 e+ S lie UQ}T(' VALID TO ,ld DRIVEWAYS: <br /> (Applicant Name) STREET q,ti/ XP. <br /> AREA QUAD /t/5 <br /> 1'11 Zs 15, 1A W u 2.6 TYPE 7 T D.2�✓E <br /> (Mail' g Address) FORMS <br /> NOTES <br /> �-+rlot�.yi., C�, 85236 <br /> (City,State,Zip Code) <br /> f 1 99-7 — 3-110 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The and i hreby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately R�feevmile <br /> Of <br /> 3S by performing the following work(description of work): <br /> callf.4,114 &A101.ons -I s il. i e. ) <br /> r. 26 <br /> 6ttiX' <br /> 1 -. S* Agkg4"AYL. <br /> Work will commence on or about loin for approximately. One— 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 /> T'.WMMA <br /> Signature ofApplicant-Title � Date <br /> STERPMWA0A0W DR PERMRAP'UCATION.DOC(01M) <br />