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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / � — 2- OFFICE USE ONLY <br /> To: San Joaquin County JOBS 73,10REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> �67 311 It-77 <br /> VALID 0 DRIVEWAYS: <br /> (Applicant Name) STREET ,�Jy�, x <br /> AREA ,� Al QUAD �S <br /> �1� �� TYPE o Ve ►W / ,� <br /> (Mailing Address) FORMS tt�sl�/ Z -r/ �r ,.2�/ «y <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 permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the " side of 5'41 41 A) ,l,t��n dor approximately .___ ile S <br /> of Fre w� cn-�' �r�A °yam � by performing the following work(description of work): <br /> Work will commence on or about �:z®v for approximately d '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 /> 4- Pyr I� r�" tw9-/-3 <br /> Signature of Applicant-Title Date <br /> MICENTRALSERMESICLERICALIPU9-SV.WKWASTER.PSIENCROACHMENTPERMITAPPLICATION DOC(09113) <br />