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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date co 2 ( OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110005- REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE _ *7 r is <br /> S'Q t 0 ln` 1 VALID - 1i� TO iS DRIVEWAYS: <br /> (Applicant Name) STREET MCA--#--.ay R , # ii lJ A- RD <br /> AREA Z5eAU.—I QUAD 51e ' <br /> GQ TYPE �rFIG Gpn�7"Qo�E5 <br /> � <br /> { (Mailing ddress) p FORMS <br /> 1 �tOctPS � C� q -?s--8NOTES <br /> (City,State,Zip Code) <br /> Zcq-!�-2-r-413c <br /> (Area Code-Telephone Number—)- <br /> 7 <br /> umber) <br /> Sketch(Detailed plans may be submitted) <br /> g&E ,4�T,9cHEA� SK�Tc�I <br /> The undersig ed hereby applies for permission to excavate,construct and/or otherwise encroach on County HighwaRight-of-Way on <br /> the N W ide of_ft f a,, , -A-Vu /?d t approximately Soo fe( gy Right-of-Way <br /> e <br /> of by performing the following work(description of work): <br /> Qcdt^9 u d aK cl l24Cg,r-t air�� S ftc,u ffn <br /> Work will commence on or about to 2vc - <br /> for approximately b c4Q,, c <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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signa -2- 26 �5 <br /> p ti t-Title <br /> Y:IGORMS S TEMPUTESIENCROACHAENTPERMIT APPiICATION.deC(CBNBj <br /> Date <br />