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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 )— t OFFICE USE ONLY <br /> To: San Joaquin County JOB# ����' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> L 'eZ VALID /7 /Q TO DRIVEWAYS: <br /> (Applicant Narhe) STREET07- �. <br /> _ AREA �i�/ n/ QUAD �E <br /> SS- TYPE -rOAO oy91� <br /> (Mailing Address) FORMS <br /> L c NOTES <br /> (City,State,zip Code) y ""Ay 101RglJIIAZ tehl &pe <br /> ?.FJ - Vf32 6 Y 7 IOre=Sn�.a-r� i NI 7 <br /> (Area Code a Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> � T <br /> o .4rzi <br /> pd ,fir 3 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the rp side of j7&i1 T approximately feet(mile <br /> of �a .by performing the following work(description of work): <br /> Cl- S c �nrT— S ���v-�-Ts <br /> S 77AF Oft I <br /> Work will commence on or about /'7 for approximately 0 eve C I days. <br /> 1,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 /> Signature of Applicant o Title Date <br /> PSL"CENTRALSERVICES5CU9;3CALIPU6SV.WKVAASTgtp51ENCROACH91Et4TPE 7irrAppL1CKnoK0Q; (09ry3) <br /> 1 <br />