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APPLICATION FOR EMCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Sr 1/11 S OFFICE USE ONLY <br /> To: San Joaquin County JOB# '] 3 )( j 7 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ <br /> r <br /> VALID <br /> (Applicant Name) STREET TO —�'�-1S DRIVEWAYS: <br /> ,,•• ff Lr I:� .. <br /> If b g V �P - �d✓ AREA r QUAD _ <br /> TYPE <br /> t <br /> (Mailing AddreSS) FORMS : �- \ S <br /> NOTES <br /> (City,Stage,Zip Code) <br /> Py-3/tom- 17 G7 <br /> (Area Code-Telephone dilumber) <br /> Sketch(Detailed plans may be submitted) <br /> -f TAC9+ ',s <br /> ZI2yo <br /> The un ersigned hereby applies for ermissio to excavate,construct and/or otherwise encroach on County Highway Right-of-W on <br /> the side of /��C �y <br /> of approximately 7? Y mile Z->&41, . <br /> 5 � by performing the following work(description of work): <br /> Lc <br /> Work will commence on or about <br /> for approximately ��� 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 a n accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i e of Applicant-Title <br /> Date <br /> hI:ICENTRAL"RNCESICLERICALIPUMV.V,'KUAASTQ2.PS1e4CROACHPAEHTPERIARAPPLICATION.00C(09J13) <br />