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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -fin x� l OFFICE USE ONLY <br /> To: San Joaquin County JOB# l/pis REF# <br /> Department of Public Works APN CR# <br /> I EXP.DATE <br /> n Lin VALID TO -54-15 DRIVEWAYS: <br /> (Applicant Name) STREET �►?DNr, a QD� h?ouc"Ag 20f ASN RD, <br /> AREA 9145KJ QUAD _ <br /> TYPE 77EM06KAXY _L1.deyAg / <br /> (Mailing Address) FORMS .� <br /> NOTES <br /> �4 9 S3c0c0 zoosbe4M 7115' :/s <br /> (City,State,Zip Code) <br /> 1a�°I�59q •��Q� <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ,be-e- C3t��2 CoU.X'Se— m(L� <br /> Kdr1ke, Ra, <br /> Cast' . \ Coka3cia- K, �'u r n c3,iro�,�nd cid bo,c�C� <br /> cam..\ Ak& cLr1d VJ a�esrs�c.�'�,rs ca.����b� c�: t 1 c�,o �,t•�,�c.�.,�xe. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately--~' feet/mile <br /> of by performing the following work(description of work): <br /> { q.0 _ z SX <br /> ` <br /> Cit Q�ki,r l l e t WW- r dry <br /> WoTk will commence�i r-af3e�rt__( c ,q}fit`; _for approx ately--.'.,-�� <br /> I,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 /> e ofApplicant-Title Date <br /> M10ENTRALSERVICESICLEWCALIPUB-SV.WMINASTER.PSIENCROACHMENT PERMIT APPLICATION.000 (0.9113) <br />