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APPLICATION FOR ENCROACHMENT"PERMIT <br /> PLEASE PRINT: <br /> Date :4*5i- OFFICE USE ONLY <br /> To: San Joaquin County FAP <br /> # REF <br /> Departm t of Public Works CR# <br /> Q <br /> EXP-DATE <br /> Qnn VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> V IOU, TYPE <br /> (Mailing dress) FORMS <br /> NOTES <br /> F (City,State,Zip `Code) I <br /> A51. 3l 1 1%5 3 2- <br /> (AreCode-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 10 A <br /> The nders'gned hereby applies for ixto to ex v te,construct and/or otherwise encroach on County Nighwa Right-of-Way on <br /> the side of S. approximately_ 2ti�j While �Y-� <br /> of by performing the following work(description of work): <br /> Work will commence on or about for approximately. days. <br /> 1,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 /> hEA VAn (RI IV )s- <br /> fgna re of Applicant-Title Date <br /> :1.u:=MRAL8ERWE:;1aC17ICa-'%-U`:i 1-1111ln:51--R RAEIJ.RQa,^,,;I:"EIJTPEAU AULIiATICUDOO (M/I5) <br /> uln <br />