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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 - 13 - 2-el!;— OFFICE-USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATElal <br /> S <br /> vt 2 3 6 3 7 t 0 VALID ��-p- ;-;--- 0 � I DRIVEWAYS: <br /> (Applicant Name) STREET P6 51, <br /> AREA ,x,�.¢ori QUAD �� k <br /> _ ��O '4TYPE j t At•Maac t Zvi <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for ermission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the side of / A) OC9 St approximately 2 W`L e ile <br /> of_ #kAyy- , lg,�-r S 52 ic-r,� , by performing the following work( escription of work): <br /> Work will commence on or about '19 �;z®I.!;-- _ for approximately 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 /> A --� 9-/-3 <br /> Signature of Applicant-Title Date <br /> M_ICENTRALSERVICESICLERICALIPUS WANKIMASTER PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />