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4./rte <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> . I <br /> PLEASE PRINT: J <br /> Date [ OFFICE USE ONLY <br /> To: San Joaquin County JOB# W 136,x2-IS!REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> r(,m 'r- �{ . ���,L'�' VALID 70-2-Za1�T0 t I- - o DRIVEWAYS; <br /> (Applicant Name) STREET JF-KI„J nAtIlo ' <br /> n � AREA QUAD N <br /> TYPE .2-q- 130"f' s 4-3-SW` .11(Wt <br /> (Mailing Address) FORMS SS/GJcJ+ � <br /> NOTES <br /> (City,State,Zip Code) <br /> q16--760- 1q:52- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �acr -C1 3 <br /> The u dersi ned hereby applies for permission to xcav construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of � t^ ; approximately . I •S fee ii ..1-16�-_ <br /> of ,by performing the following work(description of work): <br /> Q.SSOG'gkC Cdwt SSe� ai <br /> ! ,e f r 6"Z<A ovi r—`✓x151st, <br /> Work will commence on or about -L 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 /> Ar PG 1:;� Iq <br /> ignature of Applicant-Title Date <br /> E7PUBSV.WW.IASIERPSIENCRCACHf1ENCAERMRMPCICAT1oMD00(OVOB) <br /> i <br />