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APPLICATION FOR EMCROACHMEMT PERMIT <br /> PLEASE PRINT: <br /> Date V4A S OFFICE USE ONLY <br /> To: San Joaquin County JOS# 73063-4- & REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE // ! 0 <br /> RVALID f) TO ` DRIVEWAYS: <br /> (APPlocant NaMe) STREET tri! 1.6) 14,04. <br /> y6go �PS�— �� AREA 5-r6e,k-7i+t.) QUAD <br /> TYPE ,� VAe <br /> (Mailing Address) NFORMS <br /> OTES <br /> (City,State,i6p Code) <br /> q OY-3/co— 17 G`7 <br /> (Area Code-Telephone 1VUrnber) <br /> Sketch(Detailed plans may be submitted) <br /> --#- cl <br /> X124® 474 42'�o ti7�� <br /> z � <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 S'�t,1-�. �j�� approximately y,� L, Z smile_ <br /> of W <br /> I DPi by performing the following work(description of work): <br /> S\,4aLrc 4- LA <br /> Work will commence on or about <br /> forapproximately-_!� (� 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 /> e " , e of Applicant e Title Date <br /> t.1:1C[li(R1 L. RNC[S1CL[FICALIFU&SViVi:l'A:,S7ER PSIEI4CROACHh/ENTPERt:11TAPPLICATICII COC(02113) <br />