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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:. 77 / <br /> Date /),-�'4 II OFFICE USE ONLY <br /> To: San Joaquin County JOB# ///,�p� REF# <br /> Department of Public Works APN CR# <br /> / EXP.DATE ,3 / 2C&65 v �S�Z� f .Z4 G. VALID 1 z y TO .0 / J2 DRIVEWAYS: <br /> (Applicant Name) STREET a. <br /> -^ AREA 6A6 6M QUAD N/,J <br /> oeow& TYPE LA L o <br /> (Mailing Address) FORMS 5=� wie62 <br /> ✓' NOTES ' <br /> (City,State,Zip Code) <br /> �y�� ���• 7s"off - <br /> (Area Code•Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 9lE A10 690,05 4P-6 fluowF� �,U Nrn/ THE GaNCtZE� Pfl✓Et7 `���G/ Tu,2n/ <br /> Do Afo-r tot)oa_.v- -Du jeIAlC-.� RQ AlY/Go64 y evEin NEs2 �4 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of '--' 4 1 . 6 4 approximately feet/mile <br /> ,of z&IQ �' ,by performing the following work(description of work): <br /> ,nor � S �,� ,c"Td2(�?-'> "' �Il�r'•� yIJ <br /> Work will commence on or about ✓- for approximately days. <br /> t,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 'th the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ignature of Applicant-Title Date <br /> EVUB,WY "TERFSIENCROACHMENt PEMTAPRJCATIONAOC(OMB) <br />