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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San JoaquinCounty JOB# IM90 REF# <br /> Department of Public Works APN CR# <br /> DA <br /> EXP.DATE 7 <br /> t11i "^�-^' y VALID TO Iy DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA � <br /> �0 B Ole1 a�7 ejy QUAD <br /> Ole ' <br /> TYPE 09 AkArrj% <br /> (Mailing Address) FORMS j <br /> NOTES <br /> �ooOgiLipGc : �-rZl'j_ <br /> ( ity,State,Zip'Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> JAt)ftNAL-r- L._(N) A�P+ Er J K1PPQ•oAc�H <br /> 90 <br /> Drt_i LAP <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the IZA&--- side of 1uOCR <br /> of p ,� ;,� approximately_ ! 4 feet/mile <br /> by performing the following work(description of work): <br /> 1R.4 u t o <br /> n '�''� 20 D i1,AG-c <br /> Work will commence on or about Zjj)n) IL- —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 des 'bed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature IF Appli /Date <br /> F%RSSVNXY44S'UU'S {pERWAPRJCATWNDDC tojaj <br />