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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date rr.�, ._ OFFICE USE ONLY <br /> To: San Joaquin County IOB# /Dyo S REF oDepar``tment of Public Works APN CR ff <br /> t Yl C..O 4 <br /> EXP-DATE j Zo <br /> n C e n T e VALID s t T DRIVEWAYS: <br /> (Applicant Name) STREET" e %� <br /> 7 AREA �._ <br /> L - 1 SCO 1 r\ PIP -4 P/— TYPE �a ia/ !ale QUURDAD <br /> (Mailing Address) �} FORMS <br /> C. k A-0;,\A-0;,\ /�C / � 0? '� NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch,(petailed plans may be submitted) <br /> L;ncolri <br /> �- Ca*r- _ <br /> G No4K W C 7 <br /> a re c,eP J <br /> hIry-D tri <br /> The undersigned hereby applies for permission to excavate;construct and/or otherwise encroach on County Highway Right-af-Way on <br /> the-I (h� # side-of <br /> j aRproximately l 13t o feetMiite_ fYOrY� <br /> J ,by performing the following work(descrtptlon of work): <br /> r <br /> -lD_. n�o� <br /> Work will commence or,or about_ c4 xi C6 <br /> focapproxlmateiyhaKr- <br /> I,the undersigned,certify that l am me owner or uta rtz vective Property,or am qualified to.epresentthe owner and. r <br /> work described above cco ance withAhe rules and regulations of San Joaquin County and su ecf to ins dto do the <br /> -- ---, q � p approval. <br /> ignature n�Applic n tle <br /> . �,iDU6;7v.WMy1d1EP.?OIRMOPMCMYE4(P_T.Irt�c1(1G�a�«.,a,�, � ���`'�`'�� a e <br />