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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 1 <br /> Date S 2,01 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO / I`L DRIVEWAYS: <br /> (Applicant Name) STREET A D. <br /> 00 V ljl�(�C�O ` gmy AREA QUAD _ /1/GtJ ' <br /> TYPE D� * <br /> (Mailing Address) FORMS .z <br /> ALM U t ��� ✓yl�.: G�-� 9 4 � NOTES <br /> or <br /> (City,State,2ip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate construct and/or otherwise encroach on County Nigher Right-of-Way on <br /> the V �}` side of W- 'lrt E,�Pb approximately �00 f(eetlmile � <br /> Of t �FrL (L CZ t1ArD by performing the following work(description of work): <br /> 1021_'—Pb;.S 07- 'y c�A(O Oil rM S A t✓ <br /> L <br /> Work will commence on or about t 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 /> AK�� co <br /> Signat re of Applica t-Title Date <br /> E.M8SV.LYNVAASTERPSIENCROACNMENTP9iMIrAYPLICATION.DOC{81108) <br />