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t 1 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / At <br /> z ' _ VALID SZi t TO G / 2 DRIVEWAYS: <br /> (Applicant Name) STREET --- <br /> AREA <br /> AREA QUAD A" <br /> 3�6 /� rjfl/clsE/� �iy� D TYPE p ' <br /> (Mailing Address) FORMS <br /> NOTES <br /> k1,44,t/1-1T � _ SSB <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,comtr ct and/or otherwise encroach on County Highv Right-of-Way on <br /> the T side of 11W-A 5Y ��✓ approximately �O fee mile <br /> of R46409�4 fO 77 X4r-'& ,by performing the following work( escription of work): <br /> 7z> f'oT/YOL� Z Gcrc�9T/o,t%S olJ TtO,eTt/ <br /> Oa771 -S/foUG .ez Off_ yA�e / Y .�75Z W. . <br /> 7125 GEES GGA/LL BC- <br /> G6KI-571AA As 14441AI ,01,,"6 <br /> Work will commence on or about �t 451&4A ale. dor 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 descriped above in accordance%viii the rules and regulations of San Joaquin County and subject to inspection and approval.ignature of Applicant-Title Date <br /> ew. vU".""'RPb E1 J p.is t'R FfRNT AVlXAtq'100 nt!:i <br />