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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:/ <br /> Date 5/ I /b OFFICE USE ONLY <br /> To: San Joaquin County JOB# � � REF# <br /> Department of Public Works APN CR# _ <br /> EXP.DATE 0 _ <br /> i M WL L_ {,L 600oxapIVALIDTO S 'a'0 DRIVEWAYS: <br /> (Applica t Name) STREET <br /> ii AREA E7GtG�—�q QUAD <br /> 1310\A. Z'S"b iT. TYPE 6 Anzot- --_-- <br /> (Mailing Address) FORMS <br /> NOTES <br /> ::Ckmp ' 85282 <br /> (City,State,Zip Code) <br /> &02.-&4r?- / ,400-3 89-7 3(.Z --- -- <br /> (Area Code-Te phone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PLEASE S'E1a 4 TA4*1iGt PL,44 <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 feet/mile <br /> of by performing the following work(description of work); <br /> PAX sJFJ- A-►'9 11.41 <br /> Work will commence on or about / for approximately zogwsC 'IF <br /> 1,the 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 des above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> em-4w .4tvua— <br /> Signatu a of Applicant-Title If © te <br /> EVU8-SVWXV44TERP8ENCRWH"PEW70PPLiCATMU DOC(Oa08( <br />