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S 'J <br /> APPUGA T ON FOR ENCROACHWONT PERMIT <br /> r' IS 2 1 1 <br /> PLEASE PRINT. L 1j <br /> 1 t <br /> Date <br /> OFFICE USE <br /> To. San Joaquin County JOB REF <br /> Department of Public Works AFN CR# <br /> EXP. <br /> gl� ---1> I I <br /> �"—A 3 1/ /�� —> VALID to 5 is- TO IS- 1(0 DRWEWAYS: <br /> (Applicant Name) STREET <br /> I ji le AREA QUAD <br /> TYPE <br /> Wailing Address) FORMS <br /> C.A NO I Es <br /> (City,State,Zip Code) <br /> 7L L <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> F'=5 C-4LLVVV? Pd <br /> 6 <br /> X — <br /> coo <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw Right-of-Wa <br /> the -15 side of gz,L j,7 A e /-,>,,� yon <br /> of Road approximately <br /> by performing the following work(description of work): <br /> 0- <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 /> Dal". <br /> Signature of Applicant-Title <br /> Date <br /> 1,(ICEtn-LSERIACESICLMCALmE�SVWKV,V,STER PSIU4GROACHMENTPEPJ.IITAPPLICATIOIlDoC(W13) <br /> I <br />