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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date `o�z� '17 <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB# �OSa—oZ0 <br /> APN REF# <br /> ('G <br /> K"-y— -1�-A EXP.DATE r CR# <br /> (Applicant Name) VALID TO /rr <br /> STREET � DRIVEWAYS: <br /> Z 10 t. WIG iz r r►v+;�s + j u+rte. Zs a AREA TYPE QUAD <br /> (Mailing Address) <br /> FORMS >M� <br /> �,rn LNv� CILI tv:- C.A 94 5`� �i NOTES <br /> (City,State,Zip Code) <br /> l -St0 <br /> (Area Code Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 1 1a Tt�� 1't wi ro/L r=14C L-C­AnwJS o�i ►ut1-0 Lit <br /> 136--12. <br /> � Ilja .waQk �n �o:ovA,r,,-ro $:oe A�►cr n, �4:Go 6;66p,^. <br /> P a <br /> PnT#41��� <br /> The undersigned hereby applies for permission to excav <br /> the sa vrN side of ,t � ate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> to 2. aPRately feeb`rnfle__ <br /> by performing the following work(descripti <br /> + o4ton of work): <br /> 4b6 L3. LS o� Nr: 161 <br /> Work will commence on or about <br /> ��ItµJ t�` for approximately_ <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 /> �Te days. <br /> work descri e above in acc rdance with the rules and regulations of San Joaquin County and subject <br /> to inspection and approval. <br /> ignature f A pl cant-Title Z j <br /> E'1PUB.SV.WKWASTER.PSIENCROACHMEHr PERMIT APPLICATION CCC pvas) Date <br />