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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7 /3/t 4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 1(0 1 <br /> A mgr,c,G � i Q lbe4a 5 AG Sbnf,"A'n VALID ID � TOp DRIVEWAYS: <br /> (Applicant Name) STREET fif'vcuS 96&A -Carro\ 164"t160 <br /> AREA -MAe4 QUAD 50 <br /> TYPE 5 PeGiflL &Jetsi— i�Ai-Ftc.C4xyl-azt PEJW-C--S <br /> (Mailing Address) FORMS <br /> NOTES A-r4e-6,te- Wb - m- 1e <br /> 1' o Oc4. 2� 20 4 Io rh vo -m2 tzap <br /> ll <br /> (City, State,Zip Code) <br /> 50- 65H - 144gq , x -7q5!!l <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) Qk e Sem <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the side of approximately t$ feet/ ile <br /> of , by performing the following work(description of work): <br /> ��p rT ��nw -'� r c9. ��� (�►cam 'j S 1, ci Jh 1Y�aA(S 5 4�ctinSe n 7 Qxn+ <br /> Please �e a�a�,�� <br /> Work will commence on or about D D for approximately r days. <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 Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> YIPORMS&TEMPLATESTNCROACHMENT PERMIT APPLICATION.doc(080) <br /> -'' Wa`I( @' (Aic-be-�es , 0r-Z5 <br />