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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> ]�� <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# //OO6S REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> ?(A licant Na a VALID TO i tr DRIVEWAYS: <br /> STREET <br /> AREA �tz�6,�Tds QUAD <br /> `�7y QA:ATrAS [.f11 �_ TYPE �� Ctrs <br /> (Mailing Address) FORMS ,Q <br /> NOTES ' <br /> ,�o�J <br /> (City,State,Zip Code) <br /> 650-Gov-o s'-:�,-Q <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Sa AlMACH ED , <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach orl County Highway Right-of-Way on <br /> the AAside of L_ �� S`T approximate/ 2 <br /> -of y—. 1 ,_feet/mlleG� <br /> Tt7 IRE�OLA�fE EXJ:S'r�/� Q.t ,by pertorrping the following work(description of work): <br /> A£ /!L A[�lsFI=Q�h�� TCS JUEi,y/ <br /> M <br /> 0 <br /> Work will commence cn or about for approximately <br /> 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 — Za 12 <br /> g App/' �ant- tle <br /> Date <br /> E'PUM IYKMMM M*N0n%0"M POW OPUrATM DOC 10101 <br />