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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> S Z-� Ll <br /> Date —:q�/ -s I OFFICE USE ONLY <br /> To: San Joaquin County JOB pp? REF.# <br /> Department of Public Works APN CR# <br /> EXP.DATE I z-!S I'-[ <br /> C i_i fZ C)P A)i A %(19 i-ERZ.n=U)cC VALID - -2a TO _)2-t S-! DRIVEWAYS: <br /> (Applicant twine) STREET <br /> AREA .S v� QUAD <br /> 1(�0 RE . QA F)9 til E TT��- ST TYPE <br /> (Mailing dress) FORMS W <br /> 5NOTES <br /> (City,State,Zip Code) <br /> a0�1I, V -� I 1 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> lam. <br /> x <br /> The undersigned hereby applies for per fission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the' tc.u)+� side of ti.ce approximately `%' e mile,-, 4� <br /> of /7.A`t e ,by performing the following work( escription ofoorl <br /> Work will commence on or about forappr xim ely days. <br /> I � S / � <br /> I,the undersigned, certify that I am the owner of the respective property,or am qualified o rep <br /> Illent 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 e Title ®ate <br /> MICENTRALSERVICES5CLERCAL1PUBSV.WK'e ASTER,PSEN-CROACHAIEFRPERAIRAPP(1CAnoRooC(09113) <br /> 1 <br />