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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# ?3o67,7 -3 - REF# <br /> Department of Public Works APN CR <br /> (� EXP. DATE 3 %I-- <br /> !L `J��7��L� VALID to 3 q— DRIVEWAYS. <br /> I �? (Applicant Name) 4'1�t.�� STREET --.5r, ' <br /> AREA STor- iJ QUAD t <br /> TYPE / rC <br /> (Mailing Address) FORMS Z <br /> CA 5 2-CY-�, NOTES <br /> (City, State, Zip Code) 1 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Ct. qq(?tu ccL� Lx-\e)r. --\c� � <br /> to <br /> - D cCcw--) ter, Lc. <br /> rhe undersigne hereby applies for permission to excavate, ccAst,ruct and/or otherwise encroach on County Highway Right-of-Way on <br /> he side pt `_' ?� rnlCi��'1 approximately feet/mile <br /> )f , by performing the following work(description of work): <br /> Nork mill commence on or about ?, for approximately days. <br /> the undersigned, ce1ify that lam the owner of the respective property, or am qualified to represent the owner and agree to do t" e <br /> �rork described above in accordance with the rules and regulations of San Jcaquin County and subject to inspection and approval. <br /> A)CK'LUL I, Pte) Cm 'i - C1 - ZL7 E"Z <br /> Signature of Applicant-Title Date <br /> r,RI95:i EMPLATESTIICROACNM-W PEFJNT APZIICA TION yc IMEB) <br />