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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date O — Z O/ CO OFFICE USE ONLY <br /> To: San Joaquin County JOB# Qa3— REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE (C it) _ <br /> VG/"/ Z O N Za/to/"N i nom. VALID glos b 1°0 al (I it, DRIVEWAYS: <br /> (Applicant Name) STREET aQE. <br /> AREA Id* bwDC4QUAD <br /> 4-3 0 (A . TYPE 124k_&LCAA, 'Qso2rt <br /> (Mailing Address) FORMS SS tcvO <br /> NOTES <br /> (City,Sfate,Zip Code) <br /> 209 - Z39- 0,536 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> tf ifc/t ® <br /> See aPQ <br /> i <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 61I u side of �,/,.�o�-� L,u. approximately <br /> :247 9 Z� feet/ <br /> of fre�,� ------, by performing the following work description of work): <br /> oss <br /> S exri <br /> Work will commence on or about_ - D/0 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 /> Al�,&z4 <br /> Sig/rAure of Applicant-Tiffle Date <br /> EAPUB-SV WKWASTER.PSIENCROACMMENT PERMIT APPLICATION.DOC t0l)08i <br />