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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date A-/13 12-o Vg- OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> t-' EXP.DATE <br /> /{"g(b tkto -1 mAb (W41'42[ ,eP SOL 1 VALID 4- -a--,z0O 41-2q-2e DRIVEWAYS: <br /> (Applicant Name) J STREET He (Lt <br /> AREA 'Siv QUAD,5C,�, <br /> Ci rc Ie- TYPE ,tCc <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See od-#-.KC k-eJ GL.21i a I , <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Wf,5+ 4 <br /> sideof N. k6NRad a <br /> ' oapproximately 4o f mile S6", 4 <br /> W Ale( <br /> A-.70- <br /> � .70- <br /> -r 2d N- ADlf , by performing the following work(description of work): <br /> CiV.e- Sv, 1 bori�gS -fz� oPeP�L(� p-F 2d� at o.�q Eaat s.^d2 O-f= <br /> N. "01-f- X-C( %-� <br /> Work will commence on or about !446-1-315- for approximately 0 W— day <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 /> vt.t.�4 S}a Ems,�e er I-Z13Z1 S <br /> Signature of Applicant-Title Date <br /> M.ICENIRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />