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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: f <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 0 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 12 <br /> P64a KAlt-I. &i V6kw A VALIDD 2 TO S 1Z- DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA #D11 QUAD &0 _ <br /> 3S0t4 Wi6- T LAWC--kSe�it� 25� TYPE <br /> (Mailing Address) FORMS fyl7 Q-29 <br /> NOTES <br /> WAR-N�a �R �l k LA 1 14-5'l 00 <br /> (City,State,Zip Code) <br /> Sto , 2�6 _ 131a <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SCC t4rin-cites -=1-1(� i u /1Nr� �i�4SLiNt 121:P�4- Lt <br /> Qll-o-jC r L- 1b8 � 1, Qi�1 '30`l 1526$ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the sideof hits►=; approximately P,00 fee mile EAS <br /> of 1'3 i%JA tEs 12-6A by performing the following work(description of work): <br /> l M-irF« Cor�i�-cit. ��i�+��- G ki P r P is L.fNri: R�P��t�Ml,�i i tLe;SiaM-i1��1 <br /> Work will commence on or about Y io t2 for approximately `l o 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 bove in actor ance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> EiPU&SV.WKLVASTER.PSIBCROACHMENTPMMITAPPUGTIOH.DDC(01M) <br /> K 120 ( � �� <br />