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APPLICATION FOR ENCROA+a1q[WEN T PERMIT <br /> PLEASE PRIMT: <br /> Date OFFICE USE ONLY <br /> I o: San Joaquin County JOB REF# <br /> Department of Public Works APN Z.2 3-( - l -I CR# <br /> /�, EXP.DATE <br /> ,/� �� — ��. VALID s-( TO 6-1 -1 5 DRIVEWAYS: <br /> Applicant Name) STREET i <br /> Z 3$�JU -� / //�✓I, <br /> /2c?/ AREA TYPE �— QUAD s <br /> (Mailing Address) FORMS Y-AIPlPe Ivry(Tre�,rti ) <br /> NOTES <br /> ity,State,Zip Code) — —— <br /> (Area Code a Telephone Number) <br /> rSkeich(Detailed plans may be submitted) _/ <br /> �1 �?c%P�l <br /> -5s7,7 12-Z-1 <br /> Gry�� 2e er Zeel c9 t2 �9f'�/� .�®/7 �/-4 - / <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right of Way on <br /> `� sidel)f 7�"irJ�,• approximate) <br /> of 2 on �� gyp` approximately... Msc'�pltion <br /> ile Z20 �j <br /> by performing the following work of work): <br /> SSr�y-emsO� <br /> r�JRAI <br /> Work v<<ill commence on or about i - ZD -Z o/ _fior approximately ,3 <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 /> Signataile of Applicant o Title <br /> Date <br /> f;1:Y„ENMUEHVICESCLEr.ICALIPUMV.WKV;,ASTER251ETL'ROACH;7EIJTPEa,,TAPPLICA-Oot�DOC(09113] . <br /> 1 <br />