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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7--- 12 — // OFFICE USE ONLY <br /> To: San Joaquin County JOB# ?Pb i i-CP REF# <br /> Department of Public Works APN CR# <br /> E— EXPDATE f2 11 <br /> VALID ✓/ 0 Sts DRIVEWAYS: <br /> /i /� �J `t�'l/(Applicant Name) STREET �',L�A6 XD-AREA t <br /> `'f D`f b �CS T L,/Y- TYPEr�rCf+�' 0®AD N <br /> (Mailing Address) FORMS <br /> C'A � � ^ NOTES <br /> _ STacr�ro�yj l/ <br /> (City,State,Zip Code) <br /> 114z - 1126 <br /> (Area Code-Telephone Number) <br /> ?m 308 4 72 &P- <br /> Sketch <br /> zSketch(Detailed plans may be submitted) <br /> Avr4z-- i4en PI-A,41 <br /> 30eA 12-6?- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Wr<rt _sideof A T'KIAIL RO. approximately 700 feet/foile <br /> Of-071-1 N. -V by performing the following work(description of work): <br /> Work will commence on or about 1 for approximately 12— 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 /> 0AIIE 1�'�.H��s —Ggs -7- I Z ll <br /> Signature of Applicant-Title Date <br /> FPU&SVWkWASIE"S NC90ACHV-`(r PULNCAPPUCAT"IWC MW) <br />