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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S 1 a 1 aoi5 <br /> OFFICE USE ONLY <br /> To: San Joaquin County FA <br /> Department of Public Works REF'# <br /> CR# <br /> -- D�pP I l he EXP.DATE <br /> VALID /S TO �S DRIVEWAYS: <br /> (Applicant Name) STREET <br /> �uEYA0yI RfsT6t15laJ �eQau.JA , � <br /> DODCr- AREA BQ1,06C QUAD ,t/GJ <br /> (lylallongAddress TYPE IZzy3�cc.katE <br /> FORMS <br /> 540CkIPM- 01 gsdV 3 NOTES ` <br /> (Cull,State,Zip Code) - -- <br /> - Ztvv Ar'vss r � <br /> (Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ` 11G7' c <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway <br /> the { } side of &_k&QU,„ tNJ;, ty g way Right-of-Way on <br /> of hC&I -,-___ _approximately R LF <br /> feet/mile <br /> �e-�CC � e pair by performing the following work(description of work): <br /> ------------ <br /> Work will commence on orabout ��N. 9 201 S <br /> � for approximately 3 <br /> I,the undersigned,certify that I am the owner of the respective property days. <br /> work des d above in accordance with the rules and regulations of San Joaquin County andrsubject to inspection and a to do the <br /> pproval. <br /> S1Gnature ofApplicant Title Q <br /> Date <br /> tA9CEMRAI_SERNCEMCLERICALIPuB-WWKVAASTERPSlENCROACH,',, pERRff AppL,CAT10ND0C(0?713) <br /> 1 <br />