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APPLBCAT�ON FOR ENCROACMMEMT PERMIT <br /> PLEASE PRINT: <br /> Date � �S� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# `i3a0S2.(P REF# <br /> Department of Public Works APN CR <br /> EXP.DATE: <br /> (S VALID ►a t, r+� TO 2 /b DRIVEWAYS: <br /> (Applicant Name) STREET e4WA&—1 SF. <br /> AREA �'oCkZD>.1 QUAD A!5 <br /> �4640 1/lW434 TYPE <br /> (Mailing Address) FORMS <br /> J�f ��^• �1/J' 9 s�-Oy NOTES <br /> (City,State,Zip Cove) <br /> L1a' _3/4- 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 Highway Right-of-Way on <br /> the 5bk� side of S�cw�✓� mile�-�irecr <br /> of �►c,,: �' t (,vi\x,61 _ _ -�!? ,IL by performing the following work(description of work): <br /> Work will commence on or about / for approximately, <br /> days. <br /> I,the undersigned,certify that I am the owner of the respective p operty,or am qualified to represent the owner and agree to do the <br /> work described ' accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> /6 A <br /> Si pplicant-T) Date <br /> A1:10Et'TR,4LSERUCESCLERICALI U&SVM'Kt'1151ER.PSIQICRCACHN.ENT FERI.SITAPPLfCATI0N.000{0./73) <br />