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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J oi c d OFF(CE USE ONLY <br /> To: San Joaquin County JOB# 00005— REF# _ <br /> Department of Public Works APN CR# <br /> �� ���� n EXP.DATE <br /> -600A-r-( i" � ® �� VALID g T6 DRIVEWAYS: <br /> (Applicant Name) STREET 11"ATKI45o" rA SS <br /> AREA j i6 SW <br /> p lVf-1 .• , �4' TYPE &Y.19A E �au57�¢lrcnoNS6.vs►a6 <br /> (Mailing Address) FORMS �- <br /> HA,1Wf&RC3 CA, NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) -- <br /> X'>' f <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the N 00-r b1 side �-AL7 approximate) 3 <br /> Y 00 +/ ee mile W Ef i <br /> of T� RS -5,6oTe '(h-T� ® by performing the following work(description of work): <br /> Work will commence on or about `��L, 2 n _for approximately Go days, <br /> I,the undersigned,certify that I am the owner of the r_ es�ectve property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with4huTuTes and regulations of San Joaquin County and subject to inspection and approval. <br /> t3oNo NGS <0 30 2, tS <br /> Signat a of Appi ant-Title Proje cT Egg;"-Lr Dat <br /> E IPU&SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (OUM) <br />