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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: �}- <br /> Date _ , f f� :� (0 <br /> C r7 <br /> �' �` > OFFICE USE ONLY <br /> —1 San Joaquin County JOB# <br /> Department of Public Works ��l C�� REF# <br /> FAPN �# <br /> EXP.DATE � � <br /> Cfl[nl <br /> A) )q A i9 I r✓Q QXELWIL VALID - <br /> (Applicant Larne) STREET TO -r '" f'n� DRIVEWAYS: <br /> 1< LA Fa Y E� [-- ST" TYPE AREA <br /> QUAD - <br /> (Halling Address) FORMS <br /> NOTES � lel v <br /> (City,State,Zip Code) _ <br /> 6x09) Lt 1ay�, <br /> —'(Area Cede a Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach County Highway Right-of-Way o <br /> they�u—. __ side of l_ S+, n <br /> of T� approximately S <br /> fee ile �- <br /> by performing the following work(description of work): <br /> r <br /> Work will commence on or about <br /> c� ° r fora ro 'mately �� <br /> l days. <br /> I,the Undersigned,certify that t am the owner of the es ective roe 1/ )5 'S <br /> work described above in accordance with the rules and regulations of an Joaquin qua(County and subject to inspection and approval. <br /> rpresent the owner and agree to oe <br /> 11 <br /> Signature of Applicant Title I <br /> ate <br /> M_10EWRA-"WCEM".EMCA RM-'VWKVAASURPSS�'CROACHMRJTPSUIRAPPUCAnoN000(09113) <br />