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APPLICATION FOR ENCROACHMENT PERMIT ' rr <br /> PLEASE PRINT: <br /> Date .f �` OFFICE USE ONLY <br /> r <br /> To: San Joaquin County JOS# f!j REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE o19-6c-1r <br /> �� L'f K VALID 13 T ,�"13 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> STREET ,2 <br /> AREAQUAD <br /> $3"72- S TYPE <br /> (Mailing Address) FORMS Z <br /> NOTES <br /> City,State,Zip Code) <br /> 6 BVs o <br /> (Area Code-Telephone Number) <br /> -�%r'�^ �-�.�'z-- �•c- max' ��r�r� �� <br /> Sketch(D tailed plans may e submitted) <br /> 6 <br /> 4 <br /> `T� �.0 �--Cd..Y,iQ i t�sA � �t• l � <br /> ,r <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighwayRight-of-Way on <br /> the side of Gt1�d<�,�-.,;e-4f �l 9 Y <br /> of P F� a <br /> approximately "9`�s ft/mile <br /> by performing the following work(description of work): <br /> wd� Ze, � <br /> G :S-dr,� <br /> Work will commence on or about / for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signat re of Applicant-Title Dat ` <br /> �.1 Ja�'c- G�-Souf�isL��r -i <br /> E:1PU t)�¢9$?fj;iB�CROACH?E PEP,ANTAPpLICATl0N.D0C(01/08) N <br />