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R FC, F <br /> APPLICATION FOR ENCROACHMENT PERMIT ; ; <br /> PLEASE PRINT: OMD/DP <br /> Date "Z��'6 r l'� OFFICE USE ONLY <br /> To: San Joaquin County JOB# yg&3W-57 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 7 /3 <br /> VALID 3 to 13 TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA -*Me/0zx) QUAD <br /> TYPE a L z-- <br /> (Mailing Address) FORMSs <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the `^1 side of cAt4 C-L' +l c- approximately mile rJ <br /> of oc-14-4eg-- A�1 , by performing the following work(description of work): <br /> Work will commence on or about 31&k-,i for approximately co f 3 6/13 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 /> , t,L✓"C-C+aL -r !� '�` — �-/ tz' <br /> Signature of Applicant-Title Date <br /> E:IPU&SV.WKIAMASTER.PSIENCROACHMENiPERMITAPPLICATION.DOC(01108) <br />