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Id <br /> A- �t 4-7 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �' OFFICE USE ONLY <br /> To San Joaquin County JOB# 7j Q U 5Z_ REF# <br /> Department of Public Works APN CR# <br /> ry j — ,/f EXP.DATE <br /> /j:�/;�' <br /> i� t �, VALIDIL-14 TO _Z- S-I S DRIVEWAYS: <br /> Pete", p(Applicant Namle) STREET /�rCn u D r <br /> � "t IErxw„� des IG`� � AREA ..— QUAD <br /> TYPE �- � ( � S <br /> (Mailing Address) FORMS 55/14/ <br /> (,{/ <br /> L <br /> (� Pi D '2 1c1 b — NOTES <br /> �y (Cityl,JState,Zip Code) <br /> -](o v - 112, ti <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 Highway Right-of-Way on <br /> the side of approximately feettmile <br /> of ,by performing the following work(description of work): <br /> t G a 1r rM <br /> too0lrr r C d1.11 <br /> 13 _ w L i- <br /> Work will commence on or about / d dt0 ! 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 /> bIt-///(-7 <br /> ignature of App cant-Title Date <br /> ewUB,<V.Wr,lk'ASTSUP.I IGROACID&7APLWAPKrATIOMO0c LOIN) <br />