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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 - 1 -9 — 2—e l!5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# j�r�., REF# <br /> �? Department of Public Works APN CR# <br /> VALID <br /> (Applicant Name) STREET DRIVEWAYS: <br /> 4v ++[t� <br /> 4 AREA 51A f� QUADO <br /> �® TYPE <br /> (Mailing Address) FORMS ,w10 ,� 74 <br /> NOTESA 4016 , <br /> j <br /> A -2b y <br /> (City,State,Zip Code) <br /> P "7in/l <br /> (Area Code-Telephone Number) <br /> SI<etch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excava e, construct and/or otherwise encroach on County Highw Right-of-Way on <br /> the side of 2S-0 ,S e, AV approximately_ e ile S <br /> of Mct,1<7-> by performing the following work(description of work): <br /> Work will commence on or about �.m -242 ® :2-4)1 for approximately_ � 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 ����,� ���r��,� � x_1-3 d �e 06- <br /> Signature of Applrcartt-Title ®ate <br /> M:ICFNTRALSERIACESICLERICALIPLIBUNNWVSTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(09113) <br />