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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 OFFICE USE ONLY <br /> To: San Joaquin County JOB# //Dlt�� REF# <br /> Department of Public Works APN CR# <br /> n �) EXP.DATE <br /> (v <br /> L <br /> �' F��F�RFJu/ r�1� VALID 2 _ TO 7 1'Z DRIVEWAYS: <br /> (Applicant Name) STREET 1 5r►?r�. 604 JW9, ,(� a�/,!°a• <br /> AREA -f',¢,�1Gy (ILIAD 3k — ' <br /> TYPE AAj - gn-zCAri, nJ <br /> (Mailing Address) FORMS 55/i�/i✓ <br /> NOTES <br /> (City,State,Zip Code) <br /> uno -( 70_0-530 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Se-rrrN{;. NEW {�eS rO(� [t T-! ST �aUNDA&)UT <br /> f tZp�—. WrLL N I^E.h -150 A:cf,!�-,S V I:A GRO UW 0- 1-row oo-i- . <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of Way on <br /> the side of approximately feet/mild <br /> Of ,by performing the following work(description of work): <br /> Work will commence on or aboute grrsm OW-Y for approximately i— 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 /> 111124 12, <br /> Signature of APel' nt-Title D e <br /> EVU04VWMMASTERPSENUWCHICOPMUAPPUrATMOD0 MM <br /> a <br />