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APPLICATION FOR ENCROACHMENT PERR41T <br /> PLEASE PRINT: ' I <br /> Datert �.� <br /> F fob OFFICE USE ONLY <br /> 10: San Joaquin County JOB# �(,� 1� 2� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 9F([_1 )_�• C)QA)I A �I�� c� ( o I Q,[ VALID — TO , — ' DRIVEWAYS: <br /> (Applicant NaMe) STREETe t�v <br /> AREA 0 R � �A�= ti �uAD)9 IE T I�f` y-T, TYPE <br /> (Mailing Address) FORMSGW , 122 ] <br /> K- 1 O NI NOTES - <br /> (City,State,Zip Code) <br /> (Area Code e'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 Hi qlay Right-of-Way on <br /> oe. IS��+'h side ofd -q'Qs 1 Ur_0-in .1tu _approximately ' fee mile <br /> ,by performing the following work(description of work): <br /> _ J i2 (QU /4 '{' 1 �C�+ I,c).3—L L Q <br /> ( t 'X Qi <br /> Act 10 3'Llzy—T <br /> Work will commence on or about i _for ap ro ima iy(co l,C� days. <br /> I,the undersigned,certify that I am the owner of the respective property, <br /> ua ��ied �r S <br /> work described above in accordance with the rules and regulations-of an Joaquin County nd subject to inspection n and approval.esent the owner and agree to do e <br /> Signature of Applicant Title Date <br /> M"EKPXBEWCEmcuRlc&v U-svwKvdAsTmP51ETCROANk'EtirPEnirrAPpucAnottw0 @qin) <br /> 1 <br />