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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ) - 9, --- n— OFFICE USE ONLY <br /> To: San Joaquin County JOB# 730079-3 REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 2 71,S /Z <br /> PA C�17-l c. V?CzLk l_ rJ 0 A A -T % —I VALID 2 i f TO 2717, DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA T2,9Gy QUAD 5A,1 <br /> 23oo tG lLe, (ZO No TYPE –,'96rucH <br /> (Mailing Address) FORMS <br /> NOTES <br /> C oc-i�'7v0 CA 96 1 a <br /> (City, State,Zip Code) <br /> 'a-0c, - L-I r) '-1 ` 1-I o 3 I <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) 1 <br /> F LE, A S r (ZV, ,,Z tti (�,�A (,F,-,f-1- c c9)Y45 PN% <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S o07 N side of 1DU 12 H NM F rzz.f;_,yz X R0 is r) approximately 9LU' feet/mile -- <br /> of G" i c2C�N�H by performing the following work(description of work): <br /> PL Ac,a G 1z.ouoi-D RT-"?,0_ A'7 GA S E 04: I'oLe c: ::n(T blvkQ-S C71 D6 c w <br /> Na.�jp'p iJ u rt la h rn r F 2 Ry R�oMD A---r7 a 9 <br /> Work will commence on or about 2 for approximately / DAY 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 accordaftT with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ; �- <br /> Signature o ppl#nt-Title Date f!f <br /> S <br /> 1 <br /> t <br /> Ll <br />