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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date (0 _ \L - 4-C 10 <br /> OFFICE IISS ONLY <br /> To: San Joaquin County JOB # ��!tsco <br /> Department of Public works r` REF ## <br /> APN CR # <br /> AT T- EXP. DATE d jS'!U <br /> VALID 2rC O TO i�}G <br /> (Applicant Name) STREE�T,�,��r4 -, DRIVEWAYS: <br /> AREA _ QUAD —-- _— <br /> TYPE ------ <br /> (Mailing Address) FORMS S <br /> S I DCK-N1.� e A 9 S,)-1 NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Fketchetailed plans may be submitted) <br /> (>S t= X77 A C-A E)3 S KETC N <br /> �.a�. <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the l}v�S'►-- <br /> S tnA►� r2.� side of <br /> —____ approximately a.1 1,1 ' <br /> of �YIg�J 1 L }� feet/mile SOQ1;-j <br /> following work (description of work) r by performing the <br /> tXtS- <br /> t�D. zo` .Ar- <br /> +� To ' pE F t e�c2 t2 uJ� ALT rZ0 , o,.{ S rtiat�74 t7 i D <br /> Arta sGQV+CCD f �Q-1���► ��� <br /> t4 �. �l 1 u G <br /> work will It on or. about (p -,n& <br /> days. for approximately <br /> I, the undersigned certify that <br /> I <br /> am the <br /> qualified to represent the Owner and workrespective <br /> Property, cr am <br /> described a <br /> accordance with the rules, regulations of San Joa bore in <br /> inspection and approval. 3u_n County and subect to <br /> u. <br /> Signature of Applicant - Titlel 10 <br /> Date <br /> {f� <br /> P <br /> 1 <br /> f <br />