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P - po <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date & OFFICE USE ONLY <br /> To: San Joaquin County JOB# , a 6,0!;- REF# <br /> Department of Public Works APN CR# <br /> _ _ EXP.DATE -t 0 <br /> AIR_ LA 1 r� NR¢�,mA `�L"rfF , ll1/'FrYftJIV VALID Wt o TO IT DRIVEWAYS: <br /> (Applicant Name) STREET s ' <br /> AREA -1V pThiul QUAD KW — <br /> �X )�_ TYPE -Trate Qa�4D L'.LDsl1 <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE At-#r Eck.. l 0p- L C E�2, VE <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 /> ffJ11X u !MALT i'f!''�t r' (Jr� �lRz 'ti3r��En✓ CS/V ' ��4,L S L'-'tjisp 4VE. <br /> Work will commence on or about !A A,-16 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 /> Signature of Applicant-Title Date <br /> HPLI&W WK%kSiFAV HIEM MM-AM CATM.DM (DIM) <br />