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APPLICA 110H FOR ENCROACHMENT PERMIT <br /> PLEASE PRUT: <br /> Date t OFFICE USE ONLY <br /> To: San Joaquin County JOB f � f7 REF.# <br /> Department of Public t/forks APN CR# <br /> 'EXP.DATE <br /> VALID — — TO DRIVEWAY <br /> - S. <br /> (,Applicant Name) STREET N`G-l��vr- �, <br /> AREA S-kcx- {p QUAD <br /> L4 l T YPE V Ur–U. (Z i <br /> - <br /> (MailingAddrers FORMS Wtl�, 2� <br /> NOTEShij G 1 <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 County Highw' ay Right of May of i <br /> the ►t side of N%.v k-irs�L- approximately i# o <br /> c <br /> Of rVr t -SES cEc PP Y (feeI�rlile t�,'� <br /> by performing the following work(description of work): <br /> Work wrill commence on or about ) IN LWI ctw- '2-0 for approximately <br /> days. <br /> 1,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 /> Signatu e of Applicant<Title Date <br /> Id:10EI Tt2!SGRl9CES1CL6;IC.�1r IES\CY2A"d�4STF::PSlG1:CRpACif.-AEhT.criAfIT APPLICAi1011.000 (09/53) <br /> 1 <br />