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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 SII OFFICE USE ONLY <br /> To: San Joaquin County JOB# ao1R—4 REF# <br /> Department of Public Works /� -7— APN CR# <br /> /�T� <br /> ( EXP.DATE <br /> VALID 0 .114 DRIVEWAYS: <br /> rr (Applicant Name) STREET <br /> F-, ®�(1/ O AREA Q /1 QUAD ' <br /> TYPE <br /> (Mailing Address) FORMS GVJ -ZS <br /> 131A NOTES <br /> (City,State,Zip Code)) <br /> J 1 -- Ll"1-3 0J <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) , J <br /> � 9�2g335 / D�- s . �&-D� , �Tac�lV <br /> VR," 3I AAE--, f l2- Q-u ATL a>U!� �L+7C-P 7a 74C- <br /> best <br /> C- <br /> b est G V or acs -J-a a PJB-sc- Co nrt$-e- f--AJ6 A/C-�E-R-- <br /> C`AA- - 3 ZA- &X31- 'IX-61�0 <br /> The un ersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of m '4vE. approximately t%mile ,0c5-T- <br /> of RkN.b Ay6 U by performing the following work escription of work): <br /> Worts will commence on or about for approximately days. <br /> I,the undersigned,certify that 1 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 Date <br /> E.'U654W"MA1TERMS'CRDA WNy WMTARLICATM DOC(OwM <br />