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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:, <br /> �1 <br /> Date (/( ULJ OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> z EXR DATE / <br /> �ISV� ,V LIQ V1l�}+✓f �'�- VALID DRIVEWAYS: <br /> (Applicant Name) STREET jj*%1,a/l re. <br /> AREA AMI N) Q AD AlE <br /> TYPE 'T6i'L!P AAAStli26 <br /> (Mailing Address) FORMS <br /> NOTES <br /> 44do C�A — 4*Af -r>111-4 i5kA6 5 4-m'k �WA) <br /> (City,State,Zip Code) 0+,1 S rS ,�.oM 7,oo ,n TD 6 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> c� <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the- side of approximately feetimile <br /> of C t rl , by erformin the following work(de cription of work): <br /> D� Culyw i5�t kr g �(�a Y1�(LCc� <br /> 5 girl C1VE 2U <br /> Work will commence on or about 21�(S for approximately '1' b Q'3r�,�n�ays. <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 /> *—% �ti V1 �r►�ecfx� <br /> Sig4nature f Ap licant-Title D to <br /> MICENTRALSEWI CE51CLERICAL"JB SV,VIMMASTER.P&I OROACHMENT PERMIT APPLICATION.000 (GBJJ3) <br />