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I <br /> AP12UCATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -712-7/1,01-2 OFFICE USE ONLY <br /> To: San Joaquin County JOB# /��'75- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE z <br /> Mme- VALID TO L DRIVEWAYS: <br /> (Applicant Name) STREET /GG <br /> {� <br /> AREA G.�"1di✓QUAD IV6 <br /> �(7� �LDF P-LgeeK iZD TYPE P17- <br /> (Mailing <br /> >T(Mailing Address) FORMS <br /> NOTES <br /> 9AnnFiv�o C_A 95032-L-1 <br /> (City,State,Zip Code) <br /> 6GO-b7D- D 530 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed Aplan-s may be submitted) <br /> eye � 71 ACME f <br /> AP W, Ib, o$oyo <br /> PTL_ C7", <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on Coun4Higay Right-of-Way on <br /> the ON R'M side ofp cL. -`f, approximately�Zr mildof by performing the followingrition of work): <br /> _ 9erwE-r—kr A ttT=LZT'V POMCyN wNTTE NI-o le7 (2) <br /> y AVL--r <br /> Work will commence on or about— r 2 for approximately S 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 /> 7 ZZ2 <br /> Signature of Applicant-Tee <br /> ate <br /> E PAMMMSTERPSE"a0WHMEW POW AMMTION DOC RL" <br />