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I <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 13 " 2 d 1j OFFICE USE ONLY <br /> To: San Joaquin County JOB# '005'"2. 4.0 REF# — <br /> Department of Public Works APN CR# <br /> � <br /> EXP.DATE _6 �� �jN� L� 23 -7 1 .2 q g VALID rB 7 rSr TO / h< DRIVEWAYS: <br /> (Applicant Name) STREET �,) _-V. <br /> AREA �"OGIc.T°4.J QUAD NS <br /> ��® (.(���� Lu h P TYPE 3611#ak t+,✓eo+ G;s <br /> (Mailing Address) FORMS 24f, rie te-A 6,'#, 1 <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 Highway Right-of-Way on <br /> the S side of 2 3 2 t JE w .°11,&") approximately Z'5� _ mile - <br /> of_F== -St 1 �5 r,2 1<'r,,>A), by performing the following work(description of work): <br /> Work will commence on or about _�q .2 d — :aP _for approximately. /_r� 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 /> Pari►o-t- 9-/-3 G .---)e 16z- <br /> Signature of Applicant-Title Date <br /> MICENTRALSERACESICLERICALIPU&SV WK&ASTER PSIENCROACHMENT PERMIT APPLICATIONDOC (09113) <br />