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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 f 1-0 1 2_ OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE $ \ 1-- <br /> _ K-c- 55+ 1 +�S VALIDI 24, VL, T t 1I, DRIVEWAYS: <br /> (Applicant Name) STREET �Q * g V D, <br /> AREA k'CtsN QUAD GC <br /> r�S C u n A ti6 R C f Q.c,E TYPE Ar' t c Gd �L DEaI 2 GES' -- <br /> (Mailing Address) FORMS s� <br /> � � 1 7 S S NOTES lop <br /> IoN-�F�E.i � <br /> City,State,Zip Code) _ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> A, A <br /> The undersigned hereby applies for permission to excavafe,construct and r o(herwise encroach on County High Right of-Way on <br /> the �s side of Oe"Lot".A. f>Yr_4 C-otv.� f j Club�jS �timately_ fee ile was <br /> of w ry v A'I F by performing the following work escription of work): <br /> Work will commence on or about -��z� t �1 2- for approximately 0 nnc days. <br /> t,the undersigned,certify that I am the owner of the respective properly,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 /> 0(1 <br /> Signature of Applicant-Title Date <br /> FY'•iPS1TP!'147aIFP.PS£Nf.-+OSCfi!€IR PFRMT AMIfAMN DOC JOI S; <br />