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APPLICATION FOR ENCROACHMENT PERMIT �M: 31�4g1 Iii <br /> PLEASE PRINT: ` ' Na*f,, (0-7/ 9()5-2"& <br /> Date $lea/14- OFFICE USE ONLY <br /> To: San Joaquin County JOB# x}.5 - REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> - � AIWY- �✓`����' VALID �'--7�.7s;1fO DRIVEWAYS: <br /> (Applicant Name) STREET ti* <br /> � <br /> AREA ^- QUAD 3 TYPE il l <br /> (Mailing Address) FORMS <br /> r' NOTES <br /> --�-res Y10 Ck 9%12,L <br /> (City,State,Zip Code) <br /> C, -5) 321 - OJ�D <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 S o Ah side of 2964-0 q;4# approximately 12M f-p�f feeYmile qlljqo'L� { <br /> of f-d by performing the following work (description of work): <br /> Work will commence on or about -U I -( -I'j -1 If for approximately days. <br /> I,the undersigned,ce 'fy that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> b1�o� <br /> ign a of Applicant-Title Date <br /> M10ENTRALSERVICES�CLERICAL�PUB-SV.WK`MASTER.PMENCROACHMENT PERMIT APPLICATION.DOC (09119) <br />