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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRIVET: <br /> Date 0 — 1 -9 — 2—e&— OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 vo 51-- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE t 15 <br /> �� 3 ��� VALID '®1f- itr T t- t 15' DRIVEWAYS: <br /> (Applicant Name) STREET 5-rAVt u m 1)0,, <br /> AREA ni'Toc_�p QUAD <br /> 410VLy AP TYPE ' i `P ',,r) Y <br /> (Mailing Address) FORMS <br /> NOTES <br /> hy) <br /> (City,State, Zip Code) <br /> 1 7 <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 `-5 side of `,��l� � �^fc�d.�c ed� approximately 6'7 ee ile <br /> of St1±k`'p A>, by performing the following work( escription of work): <br /> Work will commence on or about I,!;-- __for approximately. J--f> n 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 /> -i,h- �!,tn,� � -/-3 - 1:-:16) <br /> Signature of Applicant-Title Date <br /> MICE NTRALSERl9CESICLERICALIPU&SUR'KWASIER.P@ENCROACHMENT PERMIT APPLICATION.COC (09/73) <br />