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APPLICATION FOR ENCROAC14MEN T PERMIT <br /> PLEASE PRINT: <br /> �5 � 402_54 � i �I�� <br /> Date , OFFICE USE ONLY <br /> 10: San Joaquin County JOB# _ _7300 7 7 — REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE I O , (- I <br /> C <br /> &L 1 1='0 A l AW19 l-EVALID q_g- (4 TO 10-3 (-(.0- DRIVEWAYS: <br /> (Applicant Nar�e) STREET -�6aQ C CA y <br /> AREA1h QUAD(o�, L �/9 I—� ,l E�I�E S-T" TYPE ( <br /> C (Mailing Address)n FORMS Ste- 2 Z <br /> -NOTES <br /> (GRy,State,Zip Code) <br /> /(Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Higj�. ay Right-of-Way on <br /> the_ cu;Z_n4' side of_ ;r�c1«A , ; approximately 10( (fie f/mile ���^�? <br /> Aof <br /> �1 f(�,r r�,�, Chu �, ,by performing the following work(description of work): <br /> Worfc wil!commence an or abouf �' <br /> far approximately (n ) days. <br /> � til �Jittl <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 Joa uin Coun' <br /> q ty and subfecf to inspecfiion and approval. <br /> Signature of Applicant o Tilde k��fe <br /> PA.'ICEMRALSEWCES5CLEICAL1PU&SV.WK!AASiEFLPSIMCROACH;fETJTPEAAIITAPP(1CA-flo DOC(09113) <br /> 1 <br />