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APPLICATION FOR ENCROACHMENT T PERMIT <br /> PLEASE PRINT: <br /> Date ` f, `� ( ��f �� OFFICE USE ONLY <br /> i <br /> lo: San Joaquin County JOB# -730077 REF# <br /> Department of Public Works APN OR# <br /> _ EXP.DATE y- S-/S' . <br /> jq� i9 I-EP- L fl if i QE- VALID -ZS-I S TO 9-lS-j DRIVEWAYS: <br /> (ApplicantNarhe) STREET R-ed <br /> CU o E . �-M Fa AREA TYPE � QUAD <br /> (lyiailing Address) FORMS <br /> � NOTES - <br /> 9.54 _ - <br /> Pty,Mate,Zip Code) <br /> —ao1 I,, y ---� j 1 <br /> ��pea Code-Telephone Number) - <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for p rmission to excavate,construct andlor otherwise encroach.on County Hi hwa Righf- r Wa on <br /> the )-)&/->4. side of ), <br /> of-- n .Q <br /> �` approximately ) fee ie <br /> i by performing the following work escription of work): <br /> 1 < <br /> k <br /> Work will commence on or abo7the <br /> S ! for proximately <br /> days. <br /> E,the undersigned,certify that Iowner of the respective prop ,or am qual'�ed 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 /> 2- �o q i <br /> Signaf�are olApplicant -Tilde rr <br /> Date <br /> 1:10EMRALSERIOCESICLE21CALWa-sv.WKWIASTEp ps E,GROACHMEtJTPERAiRAPPU0AilONOOO(09113) <br /> 1 <br />