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---m <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date `S-- _ j OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110007 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATEAWD <br /> 00 IS lti <br /> �y 4, �`��t '�u� VALID TO 5 [9� DRIVEWAYS: <br /> (Applican Name) STREET � T ,�AREA QUAD ({ ` <br /> "f� ll7Y 3� TYPE kLL,O�tkr A- " <br /> (Mailing Address) FORMS 16e <br /> NOTES <br /> ., �, �, _ <br /> (City, State,Zip Code) <br /> ` (area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission toe cavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ),---side of SLr .-1 R1 6IJ.,Approximately 300 L.5-9 feet/mile�_ <br /> of ' <br /> rr�e, �a ,� [12�L e- -t- II , by performing the following work(description of work): <br /> nta C <br /> � d <br /> VL P' A C S r t�N A\Cc c pP, Pd Pte_ <br /> Work will commence ono about — — for approximately _ �D 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 /> QiA �' X-�3/ - 1a <br /> nature ot'Applicant-Title Date <br /> E IPU&SV WKWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01138) <br />