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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> 00 EXP. DATE <br /> G U J�/�� '�}�� ' (i(Q VALID I -Z Z-(C, TO -t( -15� DRIVEWAYS: <br /> (Applicant Name) STREET �„ e kph <br /> �✓j AREA ��T QUAD <br /> T TYPE b <br /> (Mailing Address) FORMS <br /> r NOTES <br /> (City,Stat ,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> R��1G� OrrB�r��ud ��Z <br /> cq,0 f <br /> kzm 61 E o IJ ",b6 <br /> Ni ��-- <br /> S�l� e- rc <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on CountyHighw Right-of-Way on <br /> the AlmdTi side of 2541') 14(Id approximately Za � `ee mile <br /> of /i by performing the following work(description of work): <br /> ova Ye"I-Xr <br /> 0 <br /> Work will commence on or about 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 /> erg Jz�Czs -t�->����,� �• j -� � l� <br /> SVture of Applicant-Title Date <br /> ao '74f- aM3 PijeA✓Se-1Vl cq� <br /> M:ICENTRALSERVICESICLERICALIPUB-SV,NIKWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />