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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � I7FDATE <br /> OFFICE USE ONLY <br /> To: San Joaquin County 9_d REF# <br /> Department'of Public Works CR# <br /> , A - ` -']A_ TO � DRIVEWAYS:(Applicant Name) W. - <br /> 30o ' <br /> TYPE AA6 <br /> �J (Mailing Address) FORMSt,,CIUAT�C-� <br /> NOTES <br /> (City,State,Zip Code) <br /> 551--- It",3 X31 <br /> (Area code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ,- T ,I--T- JDg # q, 2 y335 14/0 -- s . 1���0 O Camra <br /> e--e 477A-C� W d rle- -7'�o 10/4c E <br /> LIP-" c-, �/AA 7—, FD/2- kff "p 7' 7`?-,G <br /> ,b eSf " of T-t,s -3'0 g P/E -sc C4 fftAe-l' E AJ64 Ave-L�--7n- <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(miie <br /> of ,by performing the following work(description of work): <br /> Work will commence on or about � 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 /> Signature Applicant-Title O <br /> Date <br /> EWbryWKW.4STMP40CFA*4aWWRTUTAMrATIONWC R+iM <br />