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04127,2.01 ':5F Alel""-?-U° e, Inc:. (Tts)55926515u3 P.0011001 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PIRII Z;. <br /> Date ,P- Z ,7 , �!o/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Cepartrr ent of Public;Works APN CR# <br /> EXP.DATE �Y <br /> VALID Wi TO $ �_ DRIVEWAYS: <br /> (Applicant Name) STREET ST. iN <br /> AREA ESe.&UoAl QUAD � <br /> good TYPE ,4D eZg9,%1AkW ' <br /> (Mailing Addiress) FORMS 5W I-VA4, <br /> /Se. b <61 - NOTES <br /> (City,State,Zip Code) <br /> ST9- 01CIcr— .SdecT <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed pians 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 approximately _feet/mile <br /> of ,by performing the following work(description of work): <br /> Z <br /> Work will commence on or about_ for approximately days. <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 accordang with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> _ � ��rrJ�-,r�"-��•�ia�-fir', �'� �� f J <br /> Signature,of Applicant-Title Date <br /> isIPUL8V.W1(UWBTfiR.P6'iNGRMCf•,MENfPERMR MPU�nONpUG(o�qe) <br />