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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# MOO 61,5`y REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE o / Z-1 I <br /> cM VALID TO _f ��— DRIVEWAYS: <br /> (Applicant Name) STREET C r <br /> AREA n QUAD ` <br /> 6505 TAM 0 SRA eR ORO TYPE f & <br /> (Mailing Address) FORMS 2 <br /> 60CMN CA 9r- 7-10 NOTES <br /> (City,State,Zip Code) <br /> 650-0y-os-60 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> AA 9TAO E- <br /> to7 ��� <br /> The undersigned hereby applies for permission to excavat ,construct and/or otherwise encroach on County Highficniption <br /> ight-of-Way on <br /> the EAST" side of S. M�.k�'N L AVE approximately ild�_LI-I <br /> of ASN Sr, b performing the following work of work): <br /> YPe 9 9 ( ) <br /> O t,t.. '/ L. <br /> vJit.L, 13F— oi`) S�; iL. ER F(�UM E'. C). p <br /> Work will commence on or about �� 'Lof Z for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am quaff to represent the owner and agree to do the <br /> work described above in accordance with ft,rules and regulalim of San Joaquin County and sclbject to inspection and approval. <br /> -�- 1 Zoll <br /> Sigma m of Applimn- DW <br /> Ef'17L6V .+—',�1�7/WLtx''CePDOC pmEi) <br />