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APPLICATION FOR ENCROACHMENT PERRUT <br /> PLEASE PRINT: <br /> Date t/�Zti � '� <br /> 0,`� OFFICE USE ONLY <br /> —1 San Joaquin County JOB# 3p�j REF.# <br /> Department of Public Works APN CR 9 <br /> _ EXP.DATE ` n J <br /> C fl le I r'C) Q f A 19I �C 12I)1 C,L VALID 2 . TO ` ^ _(— ' ; - DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ AREA .. ' UAQ ` <br /> �r 9 F)9 V� 1✓T i~ ST TYPE <br /> (Failing Address) FORMS y <br /> 1 e <br /> NOTES7cC (f�CVi <br /> Sol") 4 ((,, <br /> (CRY,State,Zip Code) IF Tt <br /> IZ�.�t ✓. <br /> ► J , <br /> \\l 4 7 � ivv' �\ <br /> f• _ cZi!E� ��8 !+ N'� �F art C <br /> n L <br /> -- (Area Code o Telephone dumber) <br /> Sketch(Detailed plans may 6e submitted) <br /> The undersigned hereby applies for permission to excavate,construct andfor otherwise encroach.on County Hi I ay Righf of Way.on <br /> the--I , 1 side of_ t approximate( <br /> Of i'U60` z k 1.�r---) <br /> y, �� fee mile <br /> by performing the following work( escdptlon of work): <br /> I-A-f 4, <br /> Work will commence on or about - for approximately <br /> days. <br /> 1,the undersigned,certify that I am the owner of the respective ra / S <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval.ree to e <br /> f <br /> Signature of <br /> Applicant-Title <br /> lgate <br /> 10EWPALSEWCESCLMCAL1PURSV.WKIdASTMI'SE ICR0ACiimEMpe?hUTAPPUCA710N000(09113) <br /> 1 <br />