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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �6 /r- !-S- OFFICE USE ONLY <br /> To: San Joaquin County JOB# � REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <<�L�l <br /> c. VALID <br /> ,S`f0 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 4o 9U TYPE x <br /> (Mailing Address) FORMS <br /> Co ) '��2 os( NOTES R ttu D <br /> (City,State,Zip Code) <br /> yok - 3/(- -(767 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) ,41 eeje o <br /> S t 6 M--T A LW I-O SK r 7 C tt <br /> �M 1-1 (A 0 (1 't)Li I <br /> The undersigned hereby applies for permission to exi vate,construct and/or otherwise encroach on County High ay Right-of-Way on <br /> the� _side of approximately 1 S Z— Z�2 mile_IIe�1- <br /> of M�, �,�{„�Ku j.,.�� A�e� ,by performing the following work(description of work): <br /> Vv e- <br /> Work will commence on or about —I —I S for approximately_�p Y <br /> da s. <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 describe ve in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 1e.✓VVII+ K—�s <br /> Signa of Applicant-Title Date <br /> MICERTRALSERVICESICLERICAL%PUMV.WKIMASTER.PS%ENCROACHMENTPERMRAPPLICATION.00G(09113) <br />