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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ! ' —! <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# ?�,��; REF.# <br /> Department of Public Works APN CR# <br /> / EXP.DATE <br /> LIN LNEN 19—Te-m 11(�yyt -'7Z 0 -(�w•w c VALID �� ,�, TO a /�, �' DRIVEWAYS: <br /> (Applicant Name) STREET �irxT <br /> AREA ZIAI W QUAD <br /> Oy GSS 15TYPE /rel/!' x"t�A r7 f -,t1yu, <br /> (Mailing Address) FORMS <br /> ii n/'� / NOTES <br /> (CRY,State,Zip Code) <br /> (Area Code o Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �A <br /> J <br /> (Lo -r S-r <br /> is <br /> Li Ll Nim 'A <br /> I� 1 <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the Nog ii side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> uAv�. -t-. fzn <br /> 0k'm 9'3OA414 Ae1W0x /0-'3Q <br /> Work will commence on or about fil,4 y / ,, �.a�s- —for approximately 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 /> Si- ature of Applicant-Title Date <br /> NSI^ENTRALSEFMCESCl&:IC.4L1PU3SV.wKV.1ASiE:iPaaCROAMH lE1JTPc�,SITAPPLICAnDMDOC(09113) <br />