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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date E� tl s 2C^� C, OFFICE USE ONLY <br /> To: San Joaquin County JOB # /le91-1,9 j REF # <br /> Department of Public Works APN CR # <br /> -; <br /> EXP. DATE ?- I--OR <br /> � <br /> ;/0_ 4 Fl(zc Dl.S m I VALID TO 33 DRIVEWAYS: <br /> (Applicant Name) STREET `X=r 66<tz>i.J <br /> �C`X C 7 AREA Le,atS7 QUAD Jk a) <br /> r TYPE �cx.a l _"�.'.l►./-�' * <br /> (Mailing Address) FORMS <br /> �-- NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> r/ <br /> s <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the & �-114 side of <br /> Ott (L1� QACXt7,- &161C, 01LPF'9 - approximately x`00,-) eet ile <br /> y -performing the <br /> following work (description of work) : <br /> Y ! (_PL C�tA 17-(Z eiL.c,',—IT'L-1-rE'r"' %Zl LI <br /> Work will commence on or about s� �✓ 0'c'n for approximately <br /> 0 K.�L days, <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspec and approval. <br /> re tic t Title Date <br /> MASTER.PS\FRES®L (5/00) <br /> 49 J <br />