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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date b5 -0(J- /S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 j(,�,7� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE -1�— <br /> sLCI��1f 1T QWK ZA-(4--r VALID TO DRIVEWAYS.- <br /> (Applicant <br /> RIVEWAYS:(Applicant Name) STREET S f Rf ) ' <br /> AREA QUAD <br /> QPM I!10 TYPE 8e[Jh(1 1- _Fv-c-z -- <br /> (Mailing Address) FORMS 5 S W)4Z �Z 212� <br /> NOTES <br /> cf5'35Z -- <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> nn <br /> 5th A-7 7"a Chf�a DR A-t kf AJA -C .--��D2 C4 A f)0 s yi!�6- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Asr /00-r side of 1qq Ftoxi-A I (�,o�,) approximately l Z$�f K6 S5 2 fee ile <br /> of rM s4rnn`� „� ur na, Le, by perorming the following work Co <br /> escription of work): <br /> Work will commence on or about b o for approximately 40 days. <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 /> Signature of Applicant-Title Date <br /> v lcFWRAL iERV10EhClP1i:AWIVAASTER F—ENCROAC194NT FIEF41AVPf+'ATIOh Off' fW_/ill <br />