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APP CATION FOR ENCROACHMENT PERM11T <br /> PLEASE PRINT <br /> Date � <br /> or-FicE use ONLY <br /> To: San Joaquin County JOB# REF <br /> Department of Public Works APN <br /> CR; <br /> d0�' f q 2 ,,I ®Q 7�7 VAE/XLID <br /> AIE 2-5 /5,! Of �'t -' — DRIVEWAYS: <br /> (Appiucar t�9a�e) STREET <br /> TYPE <br /> �0 Pr9 Q PJ91/E. <br /> (Mauiing Address) FORMS <br /> NOTES '�r <br /> (City, ate, Zip Code) -- <br /> (Area Code e Telephone f ufflber) — <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permis ;,pn fo excavate, construct and/or otherwise encroach on County Nighw Right_of_Way on <br /> of e side of 5Y K Z� sS®� approximately 22� e it <br /> LV <br /> Ic V ,by performing the following work(descript on of orit): <br /> UVorl<will commence on or about_._ � �,��� ® � <br /> fior approximately �' days <br /> I, the undersigned,certify that I am the owner of the respective prope;ty,or am qualified to represenf the owner and agree io do <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval.the <br /> N-V'1114 — <br /> SignaWra od Appficant title <br /> date <br /> AfiCElfiP.AlSFRI/CESCLERICALIPUP,-SU.Wi(!;LASIER E'SIFIICROACHNEIT PERIufi APPUCh170W.00C(0.113) <br />