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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �� � 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Pub'c Works APN CR# <br /> f a YkC ( EXP.DATE / <br /> C/O U, � C�" �r1( VALID / TO / / DRIVEWAYS: <br /> (A cant NameW STREET I / a/Wer Rp <br /> g �} AREA 15724ci—c 6d QUAD <br /> # TYPE t <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) E ca <br /> ( 71V) 771 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> /11&j <br /> y3 PI <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on CountyHigAway Right-of-Way on <br /> the "c2 S .e /i side of 3 e L)'9 i�w -' mina*( l6 le0 feet/r =:) c � <br /> --of by performing the following work(description of work): <br /> Work will commence on or about F61) for approximately wcc.CS 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 /> ignature o Applicant• itl kirc,,� Date <br /> [-.ft&SV.Y'4NU'ASTCR.PSICNCROACNkENTPERA1ff APPLICATION.DOC(01108) <br />