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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date n"V-) OFFICE USE ONLY <br /> To: San Joaquin County JOB# :730077 REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> ZA)I ATEP-r-")=(L,jA 1 C,[ VALID TO _ DRIVEWAYS: <br /> (Applicant NaMe) STREET 1-1 I'It CW I/P_ <br /> AREA / QUAD = <br /> 1 Co 0 R E . �.A F� 9 VE—I"•_ S i� TYPE - 14h ;I <br /> (Mailing Address) FORMS S/l�/W R 2 <br /> NOTES <br /> - 1aC,K-i3N (—'A clic - - - <br /> (Ck,State,Zip Code) <br /> (Area Code e Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Hi h�way Right-of-.Way on <br /> the Lx)-ems{ side of • U l t i«n , Q approximately_ U� fee'ee�Arnile - <br /> of L, by performing the following work(description of work): <br /> �►�( 40300C <br /> Ac+ in 3m1 S6 1 <br /> Work will commence on or aboutI Y for ap r im tely days. <br /> , i I4 <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to rep esent 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 /> - stan°t1 <br /> Signature of Applicant-Title I Da e <br /> tUCENMALSSWCEMLMCALIPUB-WVL Y1pMBU-.1Et.CROAW,',Ie7TPSaliTAPRICAMONAOC(OP.N3J } <br />