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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 4 �t <br /> Date 1) 1S l l 4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7300 !52 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3 - 1 -75. <br /> P( VALID -2 1'Z- I S TO 3- 15-l S DRIVEWAYS: <br /> T (Applicant Name) STREET 11aA A 1I�W k <br /> AREA r QUAD <br /> TYPE <br /> (Mailing A dress) FORMS i41 �) <br /> NOTES <br /> e-4 CA 6 s�o s <br /> `` (City,9tate,Zip Code) <br /> -)4k) _Ml <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highw�ayy Right-of-Way on <br /> the Wes+ side of �/�✓� Atltv, P, approximately I �I f&et�nile <br /> of Y-0 C\ ,by performing the following work(description of work): <br /> ti^ a� `t S` Po1C t„1i " c new LiS �f2 <br /> Work will commence on or about 'maw,-yo, for approximately I 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 a rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sign atu r6 o Applicant-Title Date <br /> ki5MaR $M,CESLLEPoCAIPUB3V.K1,1VAST6tPSQ�CROACHIFI(TPEP.V,Th Pi)CAT1GH.000(N13) <br />