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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE Pte': <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> OMMI <br /> EXP.DATE <br /> L-a VALID 2 JA p TO u it DRIVEWAYS: <br /> JAppkarrt Mar ie) STREET _ , ln� <br /> 'l <br /> AREA <br /> �� QUAD 116C <br /> (Mailing Address) FORMS <br /> Ci-j' Z:JO NOTES I <br /> ( YfRate,zip Code) 7c)r�V-4— h <br /> Sketch(Defiled plans may be submitted) <br /> i <br /> The undersigned hereby applies for permission to(IMCDfate,construct and/or otherwise encroach on County Highwaa Right-of-Way on <br /> the _side of approximately 1 fee ' iie <br /> of t� c i{ by performing the following work(description of work): <br /> Work will Wince about — Z for approximately days. <br /> 1,the undersigned,cert'rfZr 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 /> � y-- ( 1 <br /> Appkarrt-Title Date <br /> E'L'LeZV.NNUMTMP .ACHMWPEI NTAPPLICATION.000(CIJM <br />