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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ?h 7 llo OFFICE USE ONLY <br /> To: San Joaquin County JOB# ,11'*49 REF# <br /> Department of Public Works APN _ CR# <br /> 1N I L AAp 2 I -T ,�'�C . EXP.DATE . Ia7l7lo <br /> /\k- rl fL Ci / VALID d 0 p p DRNEWAYS: <br /> (Applicant Name) STREET -AW SK _ <br /> 12 -S 1 9 AREA ,tom' QUAD _&19R <br /> _ S74C,,6 50 ,r /4 00 TYPE <br /> (Mailing Address) q �r FORMSS <br /> Fn!—ra CA . ! T NOTES <br /> (City,St e,Zip Code) <br /> C�1Q <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> f <br /> f, <br /> i <br /> I <br /> r <br /> The undersigg hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way n <br /> the 64S? W"SSTside of E:V71 f C.,,eyl*+^Jc4�6 approximately feet/mile j,Sd ap <br /> of L i&JEJ ?Y/ C4AM1AVr C-- ,by performing the following work(description of work):LZzmaj <br /> V T o'r— Fac;,r-7/ 44- /�i}yL M��t-r j <br /> fE� <br /> o '7I n iJ A d S�N�i!! i N .4 7 el <br /> � 'Q <br /> /a�-D C._ PCNA i�. <br /> Work will commence on or about SirP71MRAE& Z'7 a l o for approximately - <br /> 1,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 /> Com.. Ilew. 9l/��/o <br /> Signature o Applicant-Tit a Date <br /> EVI.B,SY POUTAIWCXr,M=(Oses) <br /> i <br />