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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I o 117 t S OFFICE USE ONLY <br /> To: San Joaquin County JOB# //Qpip3 REF# <br /> Department of Public Works APN — CR# <br /> r--- EXP DATE �(o — <br /> ,��' MT VALID 01 15 f0 ( DRIVEWAYS: <br /> (Applicant Name) STREET pku,M t✓ -44e- <br /> AREA <br /> JeAREA A+1}C.e.a QUAD SW <br /> V-d-r TYPE 170A c A4 &I ted teS o�ir <br /> (Mailing Address) FORMS ,Wyy <br /> NOTES 6u/ h _ <br /> 1 wogk is w�fh►+� <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 side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> ^�-v 'Ct►�-t•r-.ins 'ku.--�c,.% 0- <br /> .-A %-T- <br /> T-0 <br /> -T-0 rn r o�.+s prr c-C�,,.✓c�- 2 w <br /> Work will commence on or about to i t T for approximately Co—4 3 _ <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 /> Ic 17 % 15 <br /> Signature of Applicant-Title ate <br /> E'1 _ ASTER PSIENCROACIIIAENT PERMTAPPLICATION DOC(01108) <br />