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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2n n OFFICE USE ONLY <br /> To: San Joaquin County JOB# 77 REF# <br /> tr N Department of Public Works APN CR# <br /> mac' EXP.DATE Ip <br /> VALID V13to tO /0& dp DRIVEWAYS: <br /> (Applicant Norrie) STREET }iE k 5r, Aj're.R5EC7 io <br /> I I t AREA 1 'a` QUAD 1,15 <br /> TYPE <br /> S (Mailing Address) I FORMS11 , <br /> 9 NOTES <br /> C(ity.y State,Zip Code) <br /> (Area Code-Telephone Number)GoN <br /> r'-H <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hig ay Right-of-Way on <br /> the ' ts4-Cl2r k-C X- Fit .t Sk h& bI.o 1 approximately_ 1 a - is tee mile <br /> of ,by Performing the following work(description of work): <br /> � Wt <br /> Work will commence on or about for approximately 1 <br /> Sol D (—� '1 e�}x f?•t1 <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 ' the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title _ <br /> E'PUBSVWKM%fftRPSCOCROAO9BRP~APPUGTMDOC MUM <br />