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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date , ':" OFFICE USE ONLY <br /> To: San Joaquin County JOB # ��9�3 REF # <br /> Department of Public Works APN _ CR # <br /> EXP. DA E 20k0 <br /> r VALID l b ?,-ib TO '2UkoDRIVSWAY3: <br /> (Applicant Name) STREET <br /> AREA _ QUAD !� _ <br /> j �� � � �� TYPE '�Gp Anckor <br /> (Mailing Address) FORMS hJ <br /> _ NOTE <br /> (City, State, !Lip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 7\ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> - otherwise encroach on County Highway Right-of-Waw on the � �� ' -� side of - <br /> ._ <br /> N ��" �' '`" � '�'�'�.�� approximately "`� :__ feet/mile <br /> of Lr rn � +21<_t�: � N �t ' >; ,� , ttg` by performing the <br /> following work (description of work) : ; Pi iNC, 1tir a= <br /> AL'-5u J24-n S,l 01-12 1't,LCI�v�� T 5'a 1E3J A A A-✓ - <br /> Work will commence on or about6 for apF roximately <br /> ,- days. <br /> ? the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection an pproval. <br /> r <br /> ,o <br /> Signature o Applicant - 'Title .T- Date <br /> z-1 Ed.FS'..FSESCz I. '"G <br />