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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 - 1 -9 — 2 C p-; OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73ws-i- REF# <br /> Department of Public Works APN � CR# <br /> EXP. DATE tr ! t; _ <br /> �YA_3 1? 1�f 3 VALID W1p 1 �'S T DRIVEWAYS: <br /> (Applicant Name) STREET ,yea "Oy'e-, <br /> AREA $-r"aek-rc A) QUAD *g <br /> P� 410 94_ &-,,h oTYPE se.1( "i r'lePKe r <br /> (Mailing Address) FORMS /enol, <br /> NOTES <br /> (City,State,Zip Code) <br /> 31,�;a-- 1 `76/2 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of .5 6.$"-� �{a�,�c r approximately <br /> of A n In 0014� �2C�-'t p 42, by performing the following work(description of work): <br /> Work will commence on or about _ w a- �Py _—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 /> &rm4o-1- 9 -1-3 - 1:;-)® 16- <br /> Signature of Applicant-Title Date <br /> MICENTRALSERVICESICLERICALIPU&SV.WNIMASTER.PSIENCROACNMENTPER"ITAPPLICATION.DOC(09113) <br />