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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> P L E i S-1 PRINT: <br /> Date J�2��/� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 00 S REF# <br /> Department of Public Works APN aa-3z-0- 4Z- CR# <br /> EXP.DATE <br /> VALID <br /> (Applicant Name) STREET TO -JJ -/ - / DRIVEWAYS: <br /> lC W <br /> AREA f lec C QUA _4Z �41 <br /> - <br /> �n 0&Yl- S I L rlft� TYPE <br /> (Mailing Address) FORMS <br /> r <br /> --- � �r — L�4� NOTES <br /> (Clt dip Code) - ---- - - ---- <br /> 'G1_ 9�0 k_JS2 r- '). 333-222 <br /> e- e enhone Number) <br /> Sketch(Detailed pians may be submitted) <br /> The undersigned hereby applies or permission to excavate,.construct andfor otherwise encroach qn County Highway Right-of-Way <br /> the ?-"I- side of_ �ptw1,l r w r"- <br /> approximately b6 <br /> of `ji feet/mile }p <br /> by performing the following work(description of work): <br /> Wod(will commence on or about "l -2-61 for approximately <br /> days. <br /> 1,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 i accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 4��//2Q�� <br /> Signature of Applicant a Title Date <br /> M:ICEMRALSEFMCESCLEICALIPU&SV.WKVMSTER.PSIENCROACH,iEt4TPERMRAPPLICATION.DOC(Oatq <br /> 1 <br />