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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 401 <br /> Date 1�6 (7 / g OFFICE USE ONLY <br /> To: San Joaquin County JOB# (I 000 ' REF# <br /> Department of Public Works APN CR# <br /> ��`,�`" EXP.DATE911114 <br /> r--X,)&" '� �� 111'fl/C4�. VALID 7 1¢ TO F/ ¢ DRIVEWAYS: <br /> (Applicant Name)f STREET am LH <br /> �- l M�—��_n AREA Lock QUAD P <br /> 7(�lp ��� �` TYPE Tre <br /> �tV <br /> (Mailin Address) FORMS S S V1/WCA � Z <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> � � c rg i•t 5 t',t`—�, G� ����'i cam) <s✓�- <br /> e.v <br /> The and rsigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hight Right-of-Way on <br /> the AhMn side of 12-6Y/ tyt approximately 2f( ee)mile <br /> of by performing the following work(description of work): <br /> e, dry V <br /> !r, `fi1''��'► <br /> Work will commence on or about -7/-71 /14 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 /> Signature of Applicant-Title Date <br /> M:\CENTRALSERVICESICLERICAL%PUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.000 (09113) <br />