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CA S-1 . <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date i'D l OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE - <br /> C r�-(2-}�/ /U C-0 VALID ( -2 TO (2-I -I DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 5,3110 13 P-15/G S AREA 4ud eca QUAD SE <br /> T, TYPE Ro r e <br /> (Mailing Address) FORMS <br /> NOTES <br /> G�V6r pt; , Cr4 9ySSU <br /> (City, State,Zip Code) <br /> 78-3- Y(�-77 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) 1 T4 m& <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the&4,5 /&zST side of Ax-167-/AI X 1� approximately 7 7 file P-7-4 <br /> of Ya Fp-)7E A JE Zo f�-1 A ?���4 by performing the following work(description of work): <br /> 13 Ole E F-lZo/-1 -,7-0//1T 7t2 E DA-� w8ST Sii)& of Au,cTiN 21� T— 6-46T <br /> II T roe c4Tv ei.vic,ir= <br /> Work will commence on or about — / for approximately / 115 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 /> C00ZD11V,4 7-Z>—I <br /> 12- <br /> ignature of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPU&SV WHIMASTER PSIENCRCACHMEN-PERMIT APPLICATION AC ;Osll) <br />