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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9- S- 15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# /6005 REF# <br /> Department of Public Works APN CR# <br /> y EXP.DATE4Ivoi <br /> /�} i;i/ ' <br /> (�il�� LJ�(fcl G� Fr�#inl)� � CtEu It�DI�iX '71 VALID TO / 8 ! DRIVEWAYS: <br /> (Applicant Name) STREET aS �RpSw�!of'r7�+' v <br /> AREA f d V;t QUAD <br /> Ci 1JC'X LN II TYPE mp- I d3l� L�'e`dJ$ClI�ES <br /> (Mailing Address) FORMS 9 iA <br /> NOTES <br /> (City,State,Zip Code) <br /> too Prh 7z fD 4,6 PAI xnfo'am <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ,:See <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 feet/mile <br /> of by performing the following work(description of work): <br /> l�zu�' <br /> /' 6"n <br /> Work will commence on or about_ /r, for approximately Q-, days. <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 /> ' r2 <br /> Signature of Applicant-Title J Date <br /> E.iPUB-SV.Y4K%JASiERPS1ENCROACHMENi PER'A;TAPPLICATION000 MI <br />