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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> L <br /> Date L( v�.� I � � /_� OFFICE USE ONLY <br /> To: San Joaquin County JOB# .. REF.# <br /> Department of Public Works APN - CR# <br /> `,�/� EXP.DATE �0 — <br /> C fl L_! T=•nQQ i A V V it I-tP—6t2--LO I 1 VALID TO DRIVEWAYS: <br /> (Applicant Naito) STREET _ <br /> AREA - <br /> GJ o a E t-i9 F)9J1 C TI��- ST TYPE UAD <br /> (Mailing Address) FORMS <br /> l t <br /> 9-5a-05 -NOTES <br /> } <br /> �L-fir{:i.. z',7 .°i !�✓ � .. /�r"FY Ib'�C(/ �..i <br /> (City,State,Zip Code) <br /> (Area Cade e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> C <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County H7fe <br /> Right of-Way on <br /> of -+��--fit side of * � a approximately S mile ,�� �v,-ro �'-'�� by performing the following worription of work): <br /> �-1 11 -4 , <br /> JiX r7i <br /> Work will commence on or about ' 1 for approximately L� days. <br /> I,the undersigned,certify that I am the owner of the respective prop rty,or am qua ified 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 /> l V I <br /> 1 � l <br /> Signature of Applicant o Title ' Qgte <br /> hL•TCENTRALSBUCEaCLEPJCAL1Pl.M-WKI°dASTEPP51Ek'CROACHMEF7TPERhfRAPPLICA-noRoOC(0911 <br />