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1 � <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Y- 23— IV OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 00 S Z REF# <br /> Department of Public Works APN CR# <br /> / EXP.DATE it)-31-14, <br /> VALID r(2 -15'- /4 TO 10-31-14 DRIVEWAYS: <br /> (Applicant Name) STREET en 44n 14 <br /> AREA QUAD <br /> TYPE T."Qa f k) <br /> (Mailing Address) FORMS S VIAl I.✓ A Z`I <br /> NOTES <br /> CX r/C1560 <br /> (City, State,Zip Code) <br /> L1e77 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the ivo'e-Tf-1 side of 3'--" W-I T approximately / ?D mile &)eS <br /> of N- L 6ES>3 4r7-(. 7 ,, -r-76 N , by performing the following work(description of work): <br /> Work will commence on or about I for approximately t5 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 /> nature of Applicant-Title Date <br /> MICENTP,4LSERVICES,CLERICALIPJ&SVWNI"MSTER?SIENCROACHMENTPE'MITAPPLCA"iONDGC ;09113� <br />