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Mar 1212 07:32p The Coleman Family 209-599-6504 p.2 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ! s, <br /> Date � �, ` 3 , OFFICE USE ONLY <br /> To: San Joaquin County JOB# //gn' REF# <br /> Department of Public Works APN CR# <br /> —� EXP.DATE[ ! i1.(C� 51 QS L�`—�• VALID q / I Z TO 1 Fl,,, r DRIVEWAYS: <br /> (Applicant Name) STREET EGer3 AGS <br /> -� AREA tPOA) QUAD �' <br /> P 0 . 1 )oX TYPE <br /> (Mailing Address) FORMS <br /> � <br /> 1 _ NOTES, U)-. �� l� ,QoR 7j3oA" <br /> (City,State,Zip Code) a <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> -+D <br /> The undersigned hereby applies for permission W excavate,construct arWor otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of ,by performing the llowing work(descri tion of work): <br /> osu.�'fL r!LLP ,L0 �tl Ulce.. <br /> Work will commence on or about for approximately 2- days. <br /> Z6 1z' =3ba m --CT 130 Qtv, <br /> I,the,W4ersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> wo de ribed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 3 l� -2Z II <br /> Signature of Applicant-Title Date <br /> E^PJ&3VriKJA4£TERP�£KCR:ACHNEMPEWAfTAPHJCATMDOC (OIAB) <br />