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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 -3 — 2 d l! OFFICE USE ONLY <br /> To: San Joaquin County JOB# 130052- REF# <br /> Department of Public Works APN CR# <br /> �? G� EXP.DATE <br /> VALID /#/'?//5' TO DRIVEWAYS: <br /> (Applicant Name) STREET .,;,? S , <br /> 14l AREA Sfe"n QUAD 95 % <br /> — .���.� TYPE U ,rt►�e,+tFto-9A..6—� <br /> (Mailing Address) FORMS -Z Tte.�cl� <br /> NOTES <br /> (City, State,Zip Code) <br /> 1 -7, 7 <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 Highwa Right-of-Way on <br /> the side of�4�6� dVl aj A approximately 717 ile _ <br /> of �/ _�7®� °1e , by performing the following work(description of work): <br /> Work will commence on or about zz e � 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 /> /-?z --- 9-/.3 - ..7->e 16;- <br /> Signature of Applicant-Title <br /> Date <br /> MICENTRALSERV10ESlCLERICALIPU&SUWK0.IASTER.PSIENCROACHMENTPERMITAPPLICATIONOOC(09113) <br />