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'! # �6�-�7 Z,r APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# _ <br /> Department of Public Works APN CR# _ <br /> EXP.DATE <br /> VALID <br /> TO /S// DRIVEWAYS: <br /> (Applicant Name) STREET tv <br /> AREA06 QUAD <br /> TYPE S /Crrc�°i,.�'I <br /> (Mailing Address) FORM �4 <br /> NOTES <br /> (City,State,Zip Code) <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 S6 y-ti-, side of_ coat SUS b io approximately !37 fe(.:!Vmile lzsz�. <br /> of Mtr L; N ."0'- — i4oQ 4-Z by performing the following work(description of work): <br /> S�pK'.Jl t f X4.5 C_T7y l yz-4✓1c*C ' <br /> Work will commence on or about_ �' , for approximately !s 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 depcfibed above in accor0mce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title batt' <br /> E WUMV WMMASTER PMENCROACHM.ENi P`eRMIT APPLICATION.DOC (0106) <br />