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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 7�0 0 7 7 REF.# <br /> Department of Public Works APN CR# <br /> `,� EXP.DATE 0-�( - <br /> C>�LI r-r)RN/ A Y V 1 TE P.n:LL) 1 C C VALID TO DRIVEWAYS: <br /> �-Z/-1� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA �O L(C f(7 YI QUAD <br /> 1(o o 1< . >f A r 11 S� TYPE <br /> (FRaWngAddress) FORMS !VW <br /> K: ©N NOTES <br /> (City,State,Zip Code) <br /> 131 1 <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 Higl ay Right-of-Way Way on <br /> the w.�-t side of o t�.a approximately._ �a C) mile. N�rye <br /> °f h"'r +��` by performing the following work(description of work): <br /> ls�1 Asa r <br /> � r j <br /> Work will commence on or aboutfor approxim telt'4 da s. <br /> I' 31 1 y <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified tore rese t the owner and agree to do thye. <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> cti � 1 <br /> Signature of Applicant Title Cvl ate <br /> tk%CENMALSERACE.%CL.EiJCALIPUSSV.WhvakSTERPS1E,"OACH51e4TpERAffr4puGA710N.000(09113) <br /> I <br />