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APPLICATION FOR ENCROAC14ME!NT PERMIT <br /> PLEASE PRINT: <br /> Date t OFFICE USE ONLY <br /> 10: San Joaquin County JOB# &R..736o?�_ REF.# <br /> Department of Public Works APN CR# <br /> EXP.DATE -/L5- <br /> —LIE T=('i aA-)—1 )q )9 I VALID I- 27-2o/rTO Lh [, . 2,::, DRIVEWAYS: <br /> (Applicant Name) STREET W ,r- <br /> AREA t�3, v. QUAD <br /> 1 0 �-A F !✓ S-T" TYPE (; I <br /> (Mailing Address) FORMS <br /> FORMS S >, �2q, �'y <br /> - - S-03 C K 0 NO- 95(D-0 J -NOTES <br /> (City,State,Zip Code) <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 <br /> the_u'. County Highway Right-of-Way on <br /> z� t side of �c ti. approximately Dn fee ile i <br /> O17 f A-J by performing the following work(description of work): <br /> Mal,OA 1 e <br /> Work will commence on or about i 1 for approximately � days. <br /> 3 i5 15 y <br /> I,the undersigned,certify that I am the owner of the res-- <br /> pectiv properfy,or m qualifed 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 /> Signature of Applicant e Title —��-Date <br /> TAICEWRA(SSUCESCLEMCALIPUBSVWKVAASiQlPSIENCROACHMD4TPSWITAPPLICAnOKDOC(09113) <br /> 1 <br />