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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Data S'a 7 bols OFFIC <br /> E USE ONLY <br /> To: San Joaquin County JOB# _�/q�l�c" REF.# <br /> Department of Public Works APN <br /> /y CR# <br /> R P 1 dP I to a 1:m <br /> 'EXP.DATEl� <br /> (Applicant Name) STREET VALID . ,G� 0 �S 1S _ DRIVEWAYS: <br /> a.3 p [r DAI <br /> AREA BQrcCS QUAD Nw <br /> TYPE aKG 1u,,H6Le <br /> Mailing Address) FORMS <br /> -- jcktw. t 9Sd03 NOTES <br /> (City,State,Zip Code) — —- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Lo� �8 7_ <br /> It c d c <br /> :aa..vrwa.nw.vx.�..maw'+vuam. �� di,�Nf1 <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County High' Right-of-Way <br /> the f► Mt sideof L4% . LaSg11� nr�;,c <br /> of q }�U,t} ------� approximately_ (i ' g il - on <br /> O� by performing the following work(description of work): <br /> t r <br /> Worl(will commence on or about Aunt �n s <br /> i for approximately � <br /> ----....�...., � 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 d above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Pre aid en'k <br /> Signat a of Applicant-Title 5fO1 7 l S <br /> Date <br /> tLIMKrMSEWCESC-Mc&TUBSV.WKV.%STERP51EKROAC$I iEtIrPERMRA°PiJCA-nuu r(4513) <br />