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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1011-11 ac)13 OFFICE USE ONLY <br /> To: San Joaquin County JOB# -02425: REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE J14 13 <br /> LQ%�ie- 6r AC 24y re, 7.rrc. VALID alsig TO jibla DRIVEWAYS: <br /> (Applicant Name) STREETitrQoy�, <br /> AREA D/ QUAD AW- <br /> TYPE <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> �caramD,��v GK1 95$s�-3 <br /> (City,State,Zip Code) <br /> �CaSo� x7c) - 5153 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PuAse .e d�I��ls j �Iru�Fi� eon s a-- coed <br /> 1301 e Armsfi y <br /> Cmrn Nom,, <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the 5ou�4Arn side of_ I�r innS�Cvna ?.A approximately ;? I -amil8 jpgs-� <br /> of Ol la E- Ar mgt m i + by performing the following work(description of work): <br /> e cdvenvAm <br /> Air gme-- / <br /> y rfa <br /> lib+f <br /> q <br /> e +� 1 Visa. Sore- n1i A <br /> r '� MiA aAQ 2'f" <br /> Worn will commence on or about-ASA P for approximately_ days, <br /> 1,the undersigned,certify thati,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 /> krmi4 (ow'-deritL /0111 /1,3 <br /> Signature df Applicant-T€tle Date <br /> i WRWrF�S'e47'6EIKADCMEM%fTbT)lS;fmYx000 62f&y <br />