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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 0 7�7 REF# <br /> Department of Public Works APN CR# <br /> \,C _ _ EXP.DATE 7-)-15-l�1 l=- C)QQ I /� V V i9 I-t 9.c�( W I Q,L VALID ¢.-?-'z-15 TO ��_ (S DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> _ AREA �� <br /> QUAD <br /> 1 Co O R � . �. 9 F6 y s1� (—� ST TYPE ~ ._ <br /> � / <br /> (M � <br /> ailing Address) FORMS kZCf <br /> -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, peXmissi�o�n fio excavate,cansiruct andior°therwise encroach on County High ay Right-oi Wa on <br /> the r�-I-• side of L� approximately `fid fire mite Eo-�� <br /> of <br /> lu � by performing the following work( escription of work): <br /> 1_ , , <br /> Work will commence on or about atv I-_ for aper xi atel days. <br /> 1,the undersigned,certify that I am the owner of the respective roe ora I _I 1 �1 owner and�✓ <br /> work described above in accordance with the rules and regulations o San Joaquin alCounty and to rsubject to inspection and approval.ree to oe <br /> ILA _ � , <br /> Is <br /> Signature of Applicant e Tilde D to <br /> FA:,"EWMSEWCESICURICALVUESV.WKIAASTaZPSIErtCROACfiMeiTpERMRAPpL1CAnoRooC ppm) <br /> 1 <br />