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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> a <br /> 3 � 1 <br /> Date i I <br /> OFFICE USE ONLY <br /> To: San Joaquin County FAPN <br /> # <br /> Department of Public Works REF# <br /> CR# <br /> L EXP.DATE 10 <br /> (Applicant Name) f STREET z r, TO la DRIVEWAYS: <br /> GU/Fl L1� #T t,G y SII <br /> AREA � QUAD <br /> + LiZt$Al f )� TYPE <br /> (Marling Address) <br /> FORMS .-.-�— <br /> '�, G'' '•% NOTES <br /> (City,State,Zi JCode) <br /> L }' L <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> '7 <br /> 1 <br /> 1 <br /> The undersigned hereby applies for permission to excav te,co tract and/or otherwise encroach on County Highw Right-of-Way on <br /> the l—1 �__ side of 'i c!, "� "l r;L- <br /> of >�l approximately C Z' ile <br /> by performing the following work(description ofow ric) <br /> ' �'t",�7•.r B�-`1�`J4 7` i✓:� .a �i�X11 i t . <br /> Work will commence on or about 1 <br /> for approximately 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 /> l� <br /> IA., AIL <br /> Signature of Applicant-Title a <br /> Date <br /> E'IPU&SV.Wi(IYIASTERPSIENCitOACNMEM PEr'.NCT A,°°JCATIOY.000 (61MJ9) <br />