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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5/6 A-3 OFFICE USE ONLY <br /> To; San Joaquin County JOB# lj REF# <br /> Department of Public Works APN CR# <br /> EXP.D <br /> -{ �{ ���b��rISa�' "^; � VALID ATE D 3 3 /3 3 DRIVEWAYS: <br /> (Applicant ame) STREET <br /> AREA QUAD <br /> TYPE F <br /> (Mallin Address) FORMS <br /> NOTES W lrlG <br /> C S 2 SP AAZ� <br /> (City,State,Zip Code) G, C� <br /> «.{t <br /> �bg-- Z`ts- �Zlc� X3`1 •-$��'",stay <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 side of 55-15 /-1fifi/ 1-JL9 -PLA-)5 approximately feet/mile <br /> Of ,by performing the following work(description of work): <br /> AN17 o4rrt4 dF � <br /> A AZWA!A <br /> Work will commence on or about. 971 a /t' for approximately_ days. <br /> 1,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 /> <S "s <br /> nry• _ <br /> Signature of Applicant-Title Date <br /> E:IPUMV.WKIMASTERPSIENCROACHNIENTPERMRAPPUCATION.000{01108) <br />