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, <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 - 1 -9 — 2-e p!�; OFFICE USE ONLY <br /> To: San Joaquin County JOB# 730052--(" REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE !f f !S <br /> IP� 7 yh G(2 3.2-711-9L✓� VALID 14 T- r5' 0 DRIVEWAYS: <br /> (Applicant Name) STREET A-1T 11-7 <br /> - <br /> AREA Glry ► QUAD <br /> q0 %2 W,eg-4 TYPE & ae wyKL, err <br /> (Mailing Address) FORMS < -1t2,� <br /> NOTES <br /> k~FA CA$ q9-2 � <br /> (City,State,Zip Code) <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 N side of approximately W 'S ee ile_A) <br /> of SC>A.iP1 St 7226,lc-r p& by performing the following work( escription of work): <br /> Work will commence on or about ;:z e9P�for approximately /-Ca'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 /> &-, & w h- 9--/-3 - ---z® 16 <br /> Signature of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPU&SV WKWIASTER.PSIENCROACNMENT PERN1IT APPLICATION DOC (00113) <br />