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T t <br /> APPLICATION FOR ENCROACHMENT PERMIT F' -3 <br /> PLEASE PRINT: a t.i 'r;' <br /> Date 1 J OFFICE USE,O.NLY <br /> To: San Joaquin County f JOB# 2-jQ+ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATEg I lie� <br /> VALID <br /> $ 70 2104o DRIVEWAYS: <br /> (Applicant Name) STREET &5#0 <br /> AREA QUAD <br /> f ti 1..1 TYPE d1E ._ PL+AG�MEF <br /> (Mailing Address) FORMS <br /> iN, -.z, _ NOTES — <br /> :. �t' <br /> (City,State,Zip Code)` <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undmerijgned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_ side of 1')1\r :'tel N°= '«} approximately_ feet/mile , o4rS7' <br /> ofby performing the following work(description of work): <br /> �T � <br /> Work will commence on or abOut `t'" --3 r I�- vi- l for approximately ` ' days. <br /> I, the undersigned,certify that I am theowner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described ab +e­-'q acco dance w th the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signat, Fere of App -Title Date <br /> r ..__�- <br /> E.'flJ&S`l,WihN1,SiER.PSEYCROAC:iA1ENt�,FMIi aPP_ICAtICN.000 pips) <br />