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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 13 — OFFICE USE ONLY <br /> To: San Joaquin County JOB# " ,( REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> 31 136 633 VALID T t € l DRIVEWAYS: <br /> (Applicant Name) STREET ?id ACE <br /> AREA b A)rE J QUAD XIF <br /> g o q o W'!':"4 L"2 I e TYPE UU, t <br /> (Wailing Address) FORMS tv - �t4f 'R//** <br /> NOTES ✓ <br /> .� ktpo CA q,67-2�� Y <br /> (City,State,Zip Code) <br /> N; 6 `7 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 Highwa Right-of-Way on <br /> the ,5 side of 1 �'7S f�e�-a� S t approximately c e mile 1,a <br /> of M�rhC et 5-t, �° by performing the following work description of work): <br /> e t.9,AE <br /> Work will commence on or about �g �2C0 — �:ZepO 47 for approximately 9 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 /> A-___ &r aq,�Y- <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSEROCESCLFRICALIPU&SUWNUMSTER PMENCROACHMENT PERMIT APPLICATION DEC (09113) �` <br />