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APPLICATION FOR ENCR®ACMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# -2300 7 7 REF# <br /> Department of Public Works APN CR# <br /> \, EXP.DATE 12.- — <br /> C fl L! L C)RL-1 A Y V i9 I•ER =LU 1 IE VALID i n-10_ 14- TO -(- DRIVEWAYS: <br /> (Applicant Name) STREET \,,,/g 1.ke�� <br /> AREA 5 � QUAD _ <br /> 1(0 oa E . t-J9 r--. 'y'E'T TE ST TYPE 1 - <br /> (MailingAddress) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> �1 0 L/ -� I i <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 Hi hway Right-of-Way <br /> the LO-eon <br /> ) side of L� o�L, approximately `T d fee mile <br /> °fC�&� I <br /> by performing the following work(description of work): <br /> 3) X4 ' <br /> 11 to 2)C-) <br /> Work will commence on or about l or a roximately 0 days. <br /> Ulifie <br /> I,the undersigned, certify that I am the owner of the respective prope ,or am q 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 L pate — <br /> FA:ICENTRALSEWCEMM.ERICAUPUBSV.W,CWASiEppSIENCROACHAIENTPERhi[TAPPLICATIONDOC (0?H3) <br /> 1 <br />