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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date +J i.�vC <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Q,C VALID -2�� �O DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> _ AREA ttik% Q AD <br /> 1(0 0 r< . �A F)9 y E� t-- S, TYPE _ <br /> (Mailing Address) FORMS ��" n <br /> - �Ta L <br /> 10 i\/ `7 5�O J NOTES <br /> (City,State,Zip Code) <br /> -�(area Dade�Telephone dumber) — <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise enc oach.on County Highway Right-of-W on <br /> the 4 �-t side of ct rY� i <br /> of 1'p A ry , approximately < < fie mile ►�t,Y� , <br /> by performing the following work(�ription of work): <br /> n Y <br /> Worfc wi[I commence on or about <br /> for approximately_ l �.� days. <br /> I,the undersigned,certify that I am the owner of the respective pro � � I� <br /> work described above in accordance with the rules and regulations of San Joaquin(County andrsubject to inspection and, ppro� e <br /> al. <br /> Signature of <br /> g Applicant Title ®ate <br /> ""CEMMALSEW E"'LRICXIPU&SV.wKUkSTERpSUNCROACHA7Et4TPEF6IITAPPLIcKnoN00C cOwn) <br /> I <br />