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APPLICATION FOR ENCP®ACHMENT PERMIT <br /> PLEASE PRINT: r� <br /> Date <br /> / OFFICE USE ONLY <br /> To: San Joaquin County JOB# '7 0077 REF# <br /> Department of Public Works APN CR# <br /> _ I I(LE EXP.DATE �- ( — ( 5 <br /> CSL Tz r")P'�IN/ A '\dt Eg=c ( VALID <br /> (Applicant Mame) STREET 4-2!!Z- TO TO Z/ - -- DRIVEWAYS: <br /> a 1" <br /> _ AREA 5 taC JOr1 QUAD <br /> 1 Co r� l�I�f� LI TE S-' TYPE 610060I P C <br /> (Flailing Address) FORMS �S W k <br /> �TOLK-1 © �I ��7. � NOTES <br /> (City,State,Zip Code) <br /> (Area Code a 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 <br /> of approximately feetlmile <br /> by performing the following work(description of work): <br /> c-�- <br /> X5+4 OTS <br /> —C'') <br /> Work will commence on or about <br /> fora roximately days. <br /> f,the undersigned,certify that I am the owner of the respective prope o am c�ualifie. to re resent the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to Inspection aowner and 9 d approval.ree to do e <br /> �lggn�afureofa Lf <br /> Applicant�Tilde <br /> DRt - <br /> FA:ICENTRgLSEFMCESCLER'CAL1PU8SV.WR147ASTERPSIR'GROACH91Et.TPEAiITAPFUCAnokD00(09,13) <br /> 1 <br />