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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ^y <br /> Date "(-oC 5 OFFICE USE ONLY <br /> To: San Joaquin County JOB /fQ/ REF# <br /> Department of Public Works APN CR# <br /> CRUCS ��C�Mc�4S VALID ATE 5 0 y S z DRIVEWAYS: <br /> (Applicant Name) STREET 9.0. ' <br /> az <br /> 8560 QANTAS !�/ A-7 AREA TYPE - Quay <br /> (Illlaifing Address) FORMS <✓� <br /> STcCX.T'ot0 11 <br /> CA q Sv20�;7 NOTES <br /> (City,State,Zip Code) <br /> � ) 333- des <br /> (Area Code-Telephone Number) <br /> Sketch(DetaNed plans may be submitted) <br /> The unders ned hereby apples for permission to eeL�cavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of _j�;STr rJ 1ZL� approximately Z2 feet/mile ;er <br /> of A zC W _rJ by performing the following work(description of work): <br /> F-AsT IZ-D_ To OF' <br /> Ns'T _Z� TRIC" SO44-r14 250 "-cg t- 1-,2- ��v�,T M P- <br /> CroTv 5-g-✓xG4ZEEX. Sop' or Or= . <br /> Work will commence on or about ,57- r -2, for approximately days. <br /> 1,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 /> CGb /Nyc17-oe. T d ? - �� <br /> AI�Fignature of Applicant-Title Date <br /> F iUBSYW.YYfIERPBENLtIMOYE11f P6tl/I AVN1LA1fON OOC 101 <br />