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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date C�1 u iU��. OFFICE USE ONLY <br /> 10: San Joaquin County JOB# puf Z REF.# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> `,� _ <br /> CAL 1 1=('� A-)i A Y V TEV— 6l; 01 QE VALID I—27 TOy,S DRIVEWAYS: <br /> (Applicant Narhe) STREET r 1 . <br /> AREA UC1C `"QUAD <br /> 1 R E QA 1-6 y E 7T*E S-1 TYPE <br /> (MailingAddress) FORMS SS <br /> gZq <br /> NOTES <br /> �Ta L <br /> IL T O N O-A 01.15a-0 5 _ - <br /> (City,State,Zip Code) <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permissi n to excavate,construct and/or otherwise encroach.on County Hi ay Right-of Way on <br /> the side <br /> side of approximately fee mile <br /> zio <br /> by performing the following work( escription of work): <br /> Work will commence on or about for approximately days. <br /> 3 is rS <br /> I,the undersigned,certify that I am the owner of the respec ve prope ,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 /> Signature of Applicant e Mie ��T—Bate <br /> M:10EWRA1 UMCMCLMC&VUB-WWKV&STSU'S'MCROACHMU4TPEMI[TAPPUCA77pN000(09173 <br /> 1 <br />