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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date '� — c0 l/ OFFICE USE ONLY <br /> To: San Joac iin County JOB# 5A ) REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE It <br /> VALID 0 j/ / DRIVEWAYS: <br /> (Applicant Name) STREET 9-2. <br /> / AREA 11D01 QUAD AIM <br /> 8SO ST/��lt�ti'T�.e TYPE FUJI M ' <br /> (Mailing Address) FORMS <br /> NOTES <br /> h1�Se S�ceA, � ,vo C g<S"10 <br /> ((:ity, State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pans 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/1/oe7W _side of Ty _Aon C ,C" approximately AP,. _S/O' c le�t/mile��5T <br /> of G'o/d�V ?r¢k .& , by performin the following work(description of work): <br /> / ' ou We9774 S. ;✓;WAlee <br /> .... ,i4�ox. Sino' �alE �°Qo�O• ���J'E o G'6�E iw - a <br /> ?i.�-ynl dN _SOv rh 5��� of Tve,JE,e AV _ <br /> Work will commence on or about_ � J�/�.t/T1�2 20// for approximately o2 days. <br /> I,the undersigned, ':ertify 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 /> Signature of App cant-Title Date <br /> E'1P0BSVVVKW1ASTERP5IENCROACH',ENT PERMIT APPLICATION DOC 01QE) <br />