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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: OFFICE USE ONLY <br /> Date ��(Z JOB# �p6af REF# <br /> CR# <br /> To: San Joaquin County APN Public Works AY S:1 <br /> EXP.DATE !S n DRIVEW <br /> Department of uTO <br /> VALID D- <br /> P STREET <br /> (Applicant Name) AREA QUADS <br /> TYPE <br /> SSC!nl <br /> W to�T �'M%� i v,i� Z S a FORMS <br /> (Mailing Address) NOTES <br /> L'r i t LZ- c <br /> A q45� <br /> (City,State,Zip Code) <br /> StL .. <br /> (Area Code-Telephone Number) <br /> S`z � /h�,�-�6r.- ►� ,T ��><�i <br /> lo:a5 ���',r;�r�ucXi._ t7�''''S h-� u P►P 4.�-,v .' <br /> tans may be submitted) <br /> Sketch(Deai � <br /> b <br /> 06 <br /> IL <br /> d 4; <br /> Highway Right-of-Way on <br /> ppimately feetymile_— <br /> a lies for permission to excavate,construct and/or otherwise encroach on Countyork description of work): <br /> The undersigned hereby applies <br /> f `p, fm k,,>- '3£il� ,by performing the following (description <br /> side of N 1 b <br /> the o�•rN �� ����• �t-ronatitt o+u <br /> V; A- A00 <br /> C-A.r 0,1 �t"r <br /> _ c '�,�•u`" 406 L3. <br /> PAA i <br /> for approximately To <br /> days. <br /> agree to do the <br /> Work will commence on or about or am qualified to represent the owner and a9 approval. <br /> I,the undersigned,certify that I am the owner rules <br /> the respective property, and subject to inspection and <br /> work des <br /> ch e above in acc rdance with the rules and regulations of San Joaquin County <br /> Date <br /> ignature f A pl cant-Title <br /> EIPUR-SV W,IMASTER.RS�ENGROAGHMEI'N PERMI(AppUGA710N DOG(01108) <br />