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�' �y i Uu 3" Vii , . Y �:. N ." '7 1 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �, OFFICE USE ONLY <br /> To' San Joaquin County JOB# _ lCe*�--5 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID &I TEf DRIVEWAYS: <br /> (Applicant(dame) STREET 4 . <br /> 5 <br /> 2/0 AREA _� QUAD � <br /> yi4 _ _ TYPE �ELG�dL E w <br /> (Mailing Address FORMS —� <br /> �w NOTES <br /> l� 4459�. <br /> (City,State,Zip Code) <br /> Area de-Tel one Number) <br /> .Z5 . % ' I56� Axl <br /> Sketch( tai plans may be submitted) <br /> L.4;�O-k �. <br /> E$&Av ,6 'Tb' I)45P&:r <br /> 1 <br /> The underslgne�hereby applies for permission to excavate,conskruct andlor otherwise encroach on County Highway Right of-Way on <br /> thet�� side of �.-lkt2Lt approximately 'jam feetlml{e 4+1�5f <br /> of r'-+fit- ash �j�� _ by perfarming the following work(description of work): <br /> C-4 VATfit. M 1 Al PUX /Z-' 1 <br /> Work will commence on or about` Z64 IT for approximately days. <br /> I,the undersigned,certify that l am the owner of the respective property,or am quallfled 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 /> t <br /> Signature of Applicant-Title Date <br /> erua�vxaa�saonar�maoun-,wcuanowoa:N�1 <br />