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• i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (?-2- S Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> _ 7 EXP.DATE /f 3 <br /> �Q:'7'{ C'� — �Q S �� VALID 4filTO /s 2a/3 DRIVEWAYS: <br /> (Applicant Name) STREET ZkXtL 0D. ' <br /> / AREA `iNLLLI✓ QUAD _L( <br /> SrO Sy�i II�,�, > �✓ >�4). TYPE POZA P -E ti7F' / �✓/�dLE <br /> (Mailing Address) FORMS 25 !✓w <br /> (9/ <br /> NOTES <br /> We'd, Sc�C/n.r��.v�o , 9/-�Q.S" <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> n � 1,�'� �2���Ciy7y Oki � ince S i�•i <br /> Se e or //cL c A e eO l� CA - <br /> Pole , l''ww <br /> QM or)/- <br /> 36117 <br /> The undersign d hereby applies for permission to ex,sate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of 4, JI pc- approximately &—K-) 0 feet/mik, Slb <br /> of_ /o C < ! G�iP_n/ by performing the following worts(description of work): <br /> Work will commence on or about - for approximately 9 D 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 Applicant-Title _ Date <br /> L�.�u � ��?�- • row <br /> E1PUB riWKVMS1FPPd1£1KNGCMSM vt WY;AFPUGr104DOC COtAt) <br /> Revises �np 41e,re 76-awA e- ► AGI 12./1S�iz <br />