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APPLICATION FOR ENCROAI�HMENT PERMIT <br /> PLEASE PRINT: <br /> Date ! ��t OFFICE USE ONLY <br /> I o: San Joaquin County JOB# IP077 REF# <br /> Department of Public Works APN CR# <br /> `,� <br /> EXP.DATE 7 <br /> C fl L_I T=(�(�A-)I l� V V VALID 8/� TO 9 �J DRIVEWAYS: <br /> (Applicant{�arhe} STREET �' dJad� E• t <br /> 1 <br /> _ AREA ` V QUAD� E`. ti-.E cy' 1 TYPE - <br /> (MailingAddress) FORMS 55�� .Kle; t <br /> NOTES <br /> (Ck,State,zip Code) <br /> (aoq) --� <br /> (Area Code-telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and(or otherwise encroach on County Highway Right-of-Way on <br /> the Ko.-+h side of approximately fee ite <br /> °f ``^`` - by performing the following work( ascription of work): <br /> t <br /> ' vt- 0 3- o n'3 <br /> 1n 34 3�t <br /> Work will commence on or about f r approximately 0 days. <br /> (� 1s ry� <br /> 1,the undersigned,certify that I am the Owner of the respective property,or am q z ed 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 �' . <br /> g Applicant d Title Da e <br /> 6t3CEKiRaLs63VncEsc[S�CAI.IPU3,svt�(rt4srcR.Po'L Roec1 :E7rPER-41TAkUrAT M.-9W13) <br /> V <br />