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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: Ii 5 - l 0 Z <br /> Date /- b- OFFICE USE ONLY <br /> To: San Joaquin County JOB# (( 0 0 G1 S REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> �-'!p r f6 � ylt-lc-c1 VALID TO - S DRIVEWAYS: <br /> (Applicant Name) STREET Uo <br /> AREA � 0 QUA <br /> TYPE Ro <br /> (Mailing Address) FORMS „Wl1 IA/1 -Z <br /> NOTES <br /> C,/V5,e5I-o1-6 i CA V,530 <br /> (City, State,Zip Code) <br /> 2-5) 7250- C/ 77 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) A-ITJ,IcIv6; <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the side of �4 gA2o hj51,-1 b /�1� approximately eet/ ile tya5 i <br /> of o� ��EN�� C_i c:_X: TZI� A��►.�i'v by performing the following work escripfion of work): <br /> -o ej' ?a Lt .i El � �0 Lc3£3c'1c�i � 15�C� �f1 <br /> Work will commence on or about /5- 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 /> 4j;g2nn—atu—re of Applicant-Title Date <br /> MICENTRALSERVICE3,CLERICALIPU8-SV WKIMAS?ER PSIENCRO.ACHMENTPEP.MITAPPL,CATION DOC (00113) <br />