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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / -g — <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73�05 REF# <br /> Department of Public Works APN CR# <br /> t: � 3 6 7�� '7 EXP.DATE tr 6- <br /> P67 <br /> �"' <br /> �� �l�l I VALID �j 0 it !S DRIVEWAYS: <br /> (Applicant Name) STREET lupl �J�, <br /> q o q0 W AREA STacktaA QUAD CS <br /> �� 1j p TYPE dote <br /> (Mailing Address) FORMS Z Cui r ��� <br /> NOTES �I <br /> (City,State, Zip Code) <br /> '-Ile -77 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the = side of !b S /r/�-tru d p approximately 2� fe mile <br /> of--_� w�t IA. na -/Vis.".-5f r2c+!C �J b A) <br /> y performing the following work(description of work): <br /> 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 /> --�°<��-� P�rte►�� �a�r�%�� � ��-!.� �- �� �,�� <br /> Signature of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPU&SV.WKIMASTER.PSIENCROACHP.1ENT PERMIT APPLICATIOIJOOC(09/13) <br />