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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � L; OFFICE USE ONLY <br /> To: San Joaquin County JOB# 2 2 O 670 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ( j <br /> �J VALID �T TO DRIVEWAYS: <br /> (Applicant Name) STREET ' <br /> AREA QUAD ` <br /> _3UU /6l9T fi41le' TYPE ` <br /> (Mailing Address) FORMS <br /> NOTES <br /> 7-6Yi <br /> (City, State,Zip Code) <br /> go V l ye y3 65' <br /> (Area Code•Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S'gG/L4i'P� 7, <br /> �dl. <br /> /77 AZ&J (-7 <br /> f�lC�SC SC'C_ 1-7, PIq 1v /qe27/ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the./-hr ? ZV li r- side of o� _�AC112.1 ne4llb / `y9 approximately feet/mile /h,!:' <br /> of by performing the following work(description of work): <br /> see t1/�� I�K�'UPcQ c{JCS <br /> Work will commence on or about Jl{ri --2y�( for approximately R0 (uu PA-' U 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 /> i1 5 J v2 -aZ0/S <br /> Signature of Appli t-Title Date <br /> MV;tNI NAL'k[10CESI:LEPIC1,V1B SV WY.WS TER i'Sl K10ACHKENT FERMIT/PPLICATION NI✓- X09113) <br />