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iF-a tz C,ol-4C-A,51� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f— 1 I OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Gwr,-1!6 2fZ�{ �SEt NC0 VALID ((��7 TO DRIVEWAYS: <br /> (Applicant Name) STREET 14lood h"V(401 e <br /> 573yy )3oel sA .5—) . TYPE �0 AREA IQUAD - . <br /> (Mailing Address) FORMS �S/L,/l✓ RZ <br /> NOTES <br /> (City,State,Zip Code) <br /> ( q 2 5) -7'?3- gF77 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) S� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of--Way on <br /> the A10!77N sideof E. 1 �D�32�1aG� 1za• approximately ro(o fee He WEms' <br /> of N. �i-bE 2Akub 1ZP ACAM-PO ,by performing the following work escdnpbon of work): <br /> F2oXX- rZOM .TO/1VT 7oLE /A/ bi/zr TO J`OiNT f`'ta[.b <br /> K 71 Ll :F_Q <br /> Work will commence on or about Id — for approximately ( 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 /> F& M rT Z /y <br /> i ature of Applicant-Title Date <br /> Y1fENTMLSEANLEACIETUCJUSPtI&SV WKt4n51EA P55ENCRWOM1EXT PEriMiT MPLIGTiONpOG fC&t3) <br /> 7�5) <br />