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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ClYl `"� v�� � OFFICE USE ONLY <br /> To: San Joaquin County — JOB# (��"j,�c�"Z"j REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE 1 Q--2� t s! <br /> 1- 2N i A Wi9T'EP-,�)ELW)QE VALID TOI[} ,k-Z�It DRIVEWAYS: <br /> (Applicant Marne) STREET Sem,o w M * <br /> _ AREA QUAD � -- <br /> 1�ri OR E. QH Fa Y E� F S-TTYPE <br /> (Mailing Address) FORMS SSl[•�(,v. 2q ' lVev..EIL... <br /> �T�L K--TO N/ O-A `n 7 S , -NOTES — - - <br /> (City,State,Zip Code) <br /> (Area Code e 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 Hig Right-of Way on <br /> the K-),r4 h side of r Q C+>: approximately fee ile Qo 1 <br /> of C�rr� by performing the folio ing work escription of work): <br /> TL <br /> Work will commence on or about H for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to repres t the owhe a 1 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 /> fea LA I CU L,/--N <br /> Signature of Applicant e Tltle Dat <br /> M]CENiRALSEFMCESSCLEZICAUPUa-SV.WKUAASTERPSTzNCROACHkiEt4TPERAIRAPPLICA7lOHAOC(09113) <br /> 1 <br />