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7 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date .3 Cc) OFFICE USE ONLY <br /> To: San Joaquin County JOB# ISM5Z-1$ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 121/1-1r/15 <br /> VALID !v �3 13 0 /��s �3 DRIVEWAYS: <br /> (Applicant Name) STREET' '3i�V <br /> AREAq QUAD -59 * <br /> ( `► iE��., N s rz TYPE 'Pb1unfe <br /> (Mailing Address) FORMS Wk) <br /> GT I co 0`,j NOTES <br /> (City,State,Zip Code) <br /> 11�C „ -60- /-c)s- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate construct andfor otherwise encroach on County Highway Right-of-Way on <br /> the 11 side of S, Vel Q. � - 1'3 l vc�, _ <br /> approximately .�c.�� f #mile (� �f <br /> of A j vti �< ,by performing the following work(description of worIR <br /> k}: <br /> . ' 1h Nk b&4 <br /> ' <br /> Work will commence on or about !3 iZ 13 for approximately 10 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 /> 113 <br /> Signature of Applicant-Title Date <br /> EPUB-SY.YYAWSTER PMCRQ,CIWafiPERMTApR]CAMiDO-C(RIM) <br />