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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9/I D1/2-- OFFICE USE <br /> ONLY <br /> To: San Joaquin County JOB# �3QQ?1j,3 REF# <br /> Department of Public Works APN <br /> CR# <br /> TT" � „ - e e Z- EXP.DATE JZ y <br /> (Applicant Name �0. VALID TO Z DRIVEWAYS: <br /> STREET <br /> 0AREA <br /> 11 TYPE QUAD — <br /> (Mailing Address) FORMS <br /> -z <br /> PSn o eA– �3 7a-7 NOTES --- <br /> (City,State,Zip Code) <br /> y- SN-3831 <br /> (.Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 'See A-r�-C64-L� I�rcc�w�rte. <br /> �s <br /> D4 2 SO/ Al, 0P20 s-f cJq--etV <br /> 4-7-t47- J-e6 v oO <br /> P�a SP �vt c �iC ��o Gilt ur sft, <br /> 3/ 3 303 <br /> The undersigned hereby applies for permission to excavate,construct aril/or otherwise encroach on County Highway Right-of-Way on <br /> the side of <br /> of approximately feet/mile <br /> 4-T ,by performing the following work(description of work): <br /> /f-"'a <br /> CAO Co- <br /> nr f� <br /> I <br /> Work will commence on or about –/2 <br /> for approximately41 - 0 - 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 /> Signature of ppticant-Title <br /> Date �— <br /> E.%FtaSVWKVAASTERftVKR0ACF NT K7UTAPRR"TiON DOC 101" <br />