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0iY) 4-i J <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ���/�/�J� OFFICE USE ONLY <br /> To: San Joaquin County JOB# ��2"j REF# <br /> Department of Public Works APN CR# <br /> ,� // _ EXP.DATE /S <br /> Ai/ _10-ro J VALID 11&114 TO 4¢ !S I4 DRIVEWAYS: <br /> (Applicant Name) STREETyc! ?t Igr4d <br /> AREA QUAD ' <br /> TYPEIUB P) ' <br /> (Mailing Address) FORMS TWJ 425' <br /> _ _ NOTES <br /> (City,State,Zip Code) Sk VOIA14XA!ae 7�5 J7,4Ar <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SCS ,�1Tj flC'/f�d A��-wi/,JC,f <br /> 7gds,"lT <br /> � 2-be'86 ,Cry <br /> The undersigned hereby applies fo,�permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the /(/ `� side of approximately feet/mile <br /> of , by performing the following work(description of work): <br /> 4c1'�rly�C -TgelJ J/VS"'7 f�// <br /> oe <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 /> 4. - 11- 51- 13 <br /> %ignature of Applicant-TitoK Date <br /> E:PUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC(01108) <br />