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a ' <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 - ! ?, - 20/!;- <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# .. REF# <br /> Department of Public Works APN CR# <br /> p� EXP.DATE <br /> 7 �, 3 1 1 q 77 Z d VALID 0 ! i DRIVEWAYS: <br /> (Applicant Name) STREETflys <br /> AREA QUAD — <br /> _ �� TYPE $e l o 4�F22 CG <br /> (Mailing Address) FORMS <br /> NOTES � I <br /> fir do CA q9-� <br /> (City,State, Zip Code) <br /> 177cS- <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> the <br /> undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> th 6 side of W f 11 A) (�ra � approximately ee mile _Al <br /> of— �0Ae c� 'r,3 , by performing the following work ascription of work): <br /> Work will commence on or about____,_�.., ,tea m. �a��__ for approximately d.�� 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 /> Signature of Applicant-Title un Date <br /> M'ICENTRALSERVICESICLERICALIPUBSV.WKWASTER.PSIENCROACHI,IEIJTPERM1fITAPPLICATIONDOC (09113) <br />