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w � ! <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z_1 6�,— Z OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> L-f/L EALID ATE 3 TO 3 !n /'1- DRIVEWAYS: <br /> (Applicant Name) STREET D, <br /> AREA QUAD L <br /> /-lV to WL�T L E- TYPE <br /> (Mailing Address) FORMS !fir <br /> NOTES <br /> 8.'CO 0-/ <br /> (City, State,Zip Code) A/ zevzAf <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 13LA r G � � mss_"-Z3('7 <br /> -J7 M F( s( CA(� l v�/12(� �?'91)1 lkme- pv� 577C <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 ZS- � U���GCS lz jam_approximately feet/mile <br /> of , b performing the followin�work(description of work): <br /> vv((-C- OE- (2,t-7 ;4611 �v <br /> WMA WILL SET WT74WLTAl Z S <br /> �L (3 1 .11 <br /> 'l L H (iJ l al rte' C70&1 <br /> Wont will commence on or about-55 -- for approximately 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 /> EIPUBdY.Wr""TERPSIENCROACHMEN(PERMIT APRKAT)ON.DOC (01109) <br />