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C <br /> ( � SC APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I ��/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1/000s' REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> 154—?a — VALID p /3 TO 0 3� l3 DRIVEWAYS: <br /> (Applicant Name) STREET ;(,,4,�/,tlj <br /> ,, {.. <br /> AREA NP,5A1 QUAD <br /> �(D ft)i1G�"_,Z C t TYPE Ar��22`` <br /> (Mailing Address) FORMS O <br /> NOTES <br /> a vtCU-yN� CA 9 S 2'sCo _ 3� 24 3r00Rfil 72) <br /> (City,State,Zip Code) oo )OW <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> h( <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 approximately feet/mile <br /> of (Qr A-01r-'A� Al r3nL� by performing the following work(description of work): <br /> :��► o0 ion <br /> PY <br /> Ar,� ` n N <br /> Work will commence on or about — of r 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 /> 04 <br /> l <br /> Signature of Applicant-Title Date <br /> E)PUBSY.WKNNSTERPBIENCROAdMIEHf PERMT APPIICATIONDOC N1blj <br />