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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 .- 3 — a C i�-- OFFICE USE ONLY <br /> To: San Joaquin County JOB# S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> �61 VALID - i -Zol DRIVEWAYS: <br /> (Applicant Name) STREET V <br /> AREA (,. L QUAD N t.J <br /> 1872) TYPE "C w <br /> (Mailing Address) FORMS <br /> NOTES <br /> L j004 by�;&e-' CO 4' 3 SE3 <br /> (City,State ,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> We�clbv <br /> QQ:d <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the side of L approximately _ Oce ' fee ile ti,rN� <br /> of l�tAs:s t0 f�l7Yi�1 e d .b`�o by performing the following work(description of work): <br /> GIJvOa�brid ¢ C A <br /> W-jgk,CPi old <6"c.,'YG G- llry/,c{2�/6uf />y1t� 4�lYlp,�, <br /> �' Iiti,cu 12- " dict2:.7��e� . t3Rc,k ��II 4.0 <br /> Work will commence on or about 2 o -2— for approximately 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 /> Signature of Applicant-Title Date <br /> A <br /> /'t od-e✓s- ri 5 K6' t ._ <br /> EVIA6SV.NMAVSTEAPge4D0AD-MWPERMTAPPLICATCt4DDC p1RE) <br />