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APPLICA1nON FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � `�J,�� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> U � >o VALID 14 1 T 4— DRIVEWAYS: <br /> (Applicant Name) STREET TgAi o DR, <br /> ,, <br /> /� AREA SW4,_-l ,#,t QUAD L i/ <br /> �} ' <br /> ►,m w6ut)LH TYPE -cGMP. IZoAl. tJ-V-,U" <br /> (Mailing Address) FORMS S /waJ <br /> NOTES <br /> (City,State,Zip Code) ThAjeAns b%a NbV, IS 2z* <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PAP <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 feet/mile <br /> of Livedo Via 1 o&,-&xff4 , Ian WrA A,16 ain by performing the following work(description of work): <br /> Work will commence on or about NWL'tY14 t tS -)A--iLk 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' accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> (�Ir 4.1 sw�a - cW61 <br /> Signa Applicant-Title Date <br /> M:ICENTRALSERVICESICFRICALIPUR&SV.WWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC(M3) <br />