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APPLICATION! FO PR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ?� � OFFICE USE ONLY <br /> 10: San Joaquin County JOB# REF# <br /> Department of Public Works APN _ CR# <br /> `,�V e c�L 12_ EXP.DATE -7-1 -1 S <br /> l=(�l�l l nV I I QE VALID - Z <br /> CJ-_L5 TO 7-(,jyS DRIVEWAYS: <br /> (Applicant Name) STREET _ <br /> E . �-. 9 F �'F ST TYPE QUAD <br /> (MailingAddress) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> �0 L/ <br /> (Area Code e telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach.on County Highway Right-of-Way on <br /> the side of approximately feettmile <br /> of by performing the following work(description of work): <br /> cam. <br /> A -+ i 3q 3 C) - T. <br /> Work will commence on or about rapoximateI days. <br /> Ir4a/HSiedlo <br /> 1,the undersigned,certify that 1 am the owner of the respective property, r am 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 /> Signature of Applicant v Title D to <br /> M]CEKFRALSERVICESSCLERICAL1PUHSV.WhiAASTERPSENCROACHA1EIUPERkirr4pIJCATIONAOC(09113) 1 <br />