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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1— 1&- 4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> c~ EXP.DATE: <br /> J�� JGtl�2 �(Si�-tG`r VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 77-,,9G QUAD <br /> J2-19 I,C�t�rs ANG / rN+j` PAvF TYPED �9*11"V4 <br /> (Mailing Address) FORMS C-t7 <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 1E ATE-7-tctfF—D <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encmarh nn County Highwa Right-of-Way on <br /> the A s7 *56>>r4 side of G 142Asr "Po 4 L�- L4,jaE 'P� approximately. 3.C�O ere mile�ov'rN44 <br /> Of Irte- cF by performing the following work(description of work): <br /> M/N&2 6�`h'»r,G Pr�V�niG g— - N o�- twtPA�^�✓aD 't�r2ay� r�MP2r� NES <br /> Work will commence on or about •'E 4-- a _for approximately 1 P15 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 /> TQM• /"l�_/¢ <br /> Signature of Applicant•Title Date <br /> Y WORAS E T641PUSESIE4CROACHMENT PERbIiT APPUCATION ax JOWS) <br />