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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7gD4 REF# <br /> Department of Public Works APN CR# <br /> �jEXP.DATE t n <br /> MMA 15VZW( —tT- Acro?_tO E�� VALID 14 111 TO t DRIVEWAYS: <br /> (Applicant Name) STREET A kriwif-cmAve A„� S -e �i,vlcGEyr/Q <br /> AREA6�itta�QUAD FS <br /> `r TYPE =M f'+et�✓✓t�r►/L�tv�s S» 1.��9L3�S ptJ <br /> (Mailing Address) FORMS <br /> NOTES <br /> - ltTo ivE �"NJ �;i6/vtE <br /> (City,State,Zip Code) <br /> 41Ct5 - 07 ;::+ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <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_ ey, Q 5T N She <br /> by performing the following work(description of work): <br /> S'�Wy9 Llt� �4,va -rte!/LC�t✓i9,�ifiR��,�C1+[c� �,4C��aLfEy%�y�� <br /> L r <br /> Work will commence on or about c for approximately dam. <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 /> A pis <br /> _ � � tl <br /> Signature Applicant-Tide Date <br /> E+PUBSY.MKW+S'9t.-SENLR�wENi PERtaTMRGtMN10c(pypll <br />