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APPLICATION FOR ENCROACHMENT PERNT, <br /> PLEASE PRINT: <br /> Date �.._ t <br /> -,'� I t i ! OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE S d <br /> t <�x�i � ' .lFa bnrt�����j VALID T DRiVE4VAYS: <br /> (App icant Name) 1 STREET <br /> t�! AREA liw� QUAD A-5 <br /> l P I c ru �r4�4.� tocti Ye TYPE <br /> (Mailing Address)' FORMS <br /> NOTES <br /> (City,State,Zip Code) — <br /> (Area Cade-Telephone Number) <br /> Sketch(Detailed pians may be submitted) <br /> 5 0!1a,e5 PA e <br /> ��kE �/�4L �GG'GrYlr►1�!!�??l� yob' /1�4T" r'�'G�.E!/t.� � ;�✓t�fE�✓�y!S'. <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 l`,`A "5A4 � --t�,' approximately feettmile <br /> Of by performing the following work(description of work): <br /> Work will commence on or about__ f °s1 for approximately J days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am quatified to represent the owner and to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to ibspecfion and approval. <br /> Signature of nt-Trtie Date <br /> EiPu--ar�s•�-W,K.A.SMRpSENCROAMlIO,TpSes AppLJCAT*KDOC ro,rtM <br /> �Iee *,B <br />