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31OL1 �y�f <br /> /Va4- : 167393 'i9 <br /> L u 4 Cv APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 1 <br /> Date / / �� / OFFICE USE ONLY <br /> To: San Joaquin County JOB# -7 � OM Z REF# <br /> Department of Public Works APN CR# <br /> LIATE <br /> VALID 7 <br /> _ i TO <br /> DRIVEWAYS: I <br /> (A�,�plican�arri STREET <br /> Pc e t"'d4"'c7 Y4.0%9 S rC- AREA QUAD <br /> YS-0 5�.'JI w,�,rr �,l , wM s-� S��,, hWE r p <br /> (Mailing Address) FORMS 5Zkl)AlZ <br /> NOTES <br /> Gt�,rs�- �s��-��� ► C� 9S'�Us� <br /> (City,State,Zip Code) ^�y <br /> 7(-rJ <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 side of approximately feet/mile <br /> of _,by performin the followin work(description of work): <br /> E w I Le -c ,cl�►,'- e- 11c 7 a <br /> 009.1 3 c { MA#Ad 2S POf <br /> Work will commence on or about 1b //'7 for approximately days. <br /> I,the undersigned,certify that 1 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 /> Si ure of Applicant-Title Date <br /> IAxCa7fAAL5ERY1tE5VC1ERP..AL1?Il&SYrM-AASTERPSF.CRMHMITPMWr/FPLCAT10N.o0.(49113) l <br />