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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �� / �� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> 4 �-`� EXP.DATE S <br /> . ,�,.;,G { (1 ';{� i � . VALID /S// TO /r DRIVEWAYS: <br /> (Applicant Name)u STREET �2/lris ,Cpq S <br /> �LiC.�v�C� b t tI� ��r�. TYPE Jaz r QUAD <br /> (Mailing Address) FORMS ,QD�1D <br /> r <br /> ���'�'� is � �� !� l•�.�� NOT <br /> `?L 14 4 to (City,State,Zip Code) <br /> Rau 0.1 f <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Aolska w <br /> lid kk. . fit.w,- o <br /> 5 V y � <br /> QA& rksv4 `i�"1 ` !/�Qe Qiftp Cta _4 I <br /> E� <br /> lot-, iAi40(- 1 Li it � <br /> cmi, -�[Jy�� �� j1 y�p Qd^,}y A 7 j[l (//�[� 1 f / <br /> i <br /> The undersigned hereby applies for pe fission to a cavate,construct nd/or otherwise encroach on County Highway Right-of-Way on <br /> O <br /> the � \ sideSof i As -� approximately feet/mile <br /> °f by performing the following work descri 'on of work <br /> "N�.0 s t1•` a�lEE1 �3 �SM�fs�4�' � �IL (I Leftu <br /> j pl��' <br /> �5 ot�i/I(i <5�< <br /> E.U� � 1 f l' .►F (`1 t Y� filla 3 c� ; ' �G ��EQ•'s� ;aVn 1�2 <br /> Work will commence on or about tI '1 w1 - 01 I i `006 -,for approximately i u f; I -days. <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 /> Signature of Applicant-Title Date <br /> E'PUS-SV WKVAA.S?ERPWNCROACAMENT PERMIT A°PL!CA11Ca.0-,C 1pl") <br />