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APPLICATION FOR ENCROAC14MENT PERMIT <br /> PLEASE PRINT: <br /> Date (- <br /> �� OFFICE USE ONLY <br /> To: San Joaquin County JOB# Q . a <br /> Department of Public Works REF#APN <br /> CR# <br /> EXP.DATE j�� l <br /> L I I=(�RNi A 1�E9 =.2 0?C,L VALID Is <br /> (Applicant Name) STREET2 TO -1y) _��) �/5—DRIVEWAYS. <br /> AREA QUAD <br /> 1�0 r7, E LA r� " 1✓-Y L ST TYPE — <br /> (ivIaolmg A010ress) FORMS <br /> O A NOTES <br /> ( tYd S$a$e,Zip Code) <br /> sr. <br /> ` '(Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for p5mission to excavate,construct andlor otherwise encroach on County Hi hwa Right o{Wa <br /> the I��� side of LAID 0 1 <br /> of -- ���t _��I a Y g yon <br /> c n ---� pproximately ( ' fee miles L <br /> by performing the following work scription of work): <br /> oo- <br /> Work will commence on or about � — • <br /> for pr ximately ,J days. <br /> I,the undersigned,cer#ify that I am the owner of the respective roe I, �5��� <br /> work de P ,or u ' <br /> scnbed above in accordance with the rules and regulations o S n Joaquin ICoudnty andrsuhject toinspect p <br /> on and a to 0o the <br /> p val. <br /> r <br /> 4.gnlApp <br /> ure of lica��t Tifle Il c 1 <br /> ( Dgf'e <br /> M:"EMWALSERMCESICLERICAllPueSV.Wh'".1ASTERPS1EWROACH%iETfTPER&IITAPPUCAnONCOC(a?m) <br /> 1 <br />