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I <br /> I <br /> I <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> i <br /> Date — ��- a o i 5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7,�C6 q– REF# <br /> Department of Public Works APN CR# _ <br /> EXP.DATE E`3- 2c�-/� <br /> AST-ff Oerr-Y rfj Cpel/ 1-16k VALID .(-2v TO ��-1-2��/� DRIVEWAYS: <br /> (Applicant Name) STREET , <br /> AREA AD <br /> hVe TYPE <br /> (Mailing Address) FORMS <br /> CA NOTES ` <br /> (City,State,Zip Code) <br /> 55q - ,q 5 q - '4q- "Iq <br /> r (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 County Highway Right-of-Way on <br /> the side of_ -5 approximately 5 ti feet/mile <br /> of ll $*, p ,by performing the following work(description of work): <br /> ?? ( � Cd wod�i 7� (1> 31�[5 t �t w.a �.c! • <br /> Work will commence on or about Or !3 1S 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 /> a 9 - 00/ 5 <br /> Signature of 6plicant-Title . Date <br /> V'fEtirPAEER,.tJEMEkCALtAMSY..nWAtrERPSfl:CFOMkGElrt PEA4ittPMCAT10!t00C pull) <br />