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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLL-ASE PRINT. <br /> Date I©/k <br /> T---J _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Worlcs °����" REF# <br /> APN CR <br /> EXP.DATE t_oe-k4, <br /> y j ��, <br /> VALID <br /> (Applicant Marne) TO r la — DRIVEWAYS: <br /> STREET �d <br /> LlbtlU LIII�I r(f AREA _ n QUAD CJS <br /> TYPE <br /> (Mailing Address) FORMS <br /> MOTES <br /> (CRY,State,Zip Cede) <br /> qbb - 3i(- -/ 767 <br /> (Area—Co—de-7eieph®rae fVuniber) <br /> Sketch (Detailed plans may be submitted) <br /> 5 G TP SK <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> N r S side of e�,i .d } <br /> lick ft�–hK41 -�tul--- feet/mile <br /> by performing the following work(description of work): <br /> Wori<will commence on or about / — or approximately O days. <br /> 1, 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 accordance with the rules and regulatiors of San Joaquin County and subject to inspection and approval. <br /> Si pplicant-I We <br /> i <br /> Date <br /> 7II:ICEtURALSERUICESICLFFIGLIpUBSVI%,Kt,.'JASTER.PSOICROACPtlEIJTFERF.;ITAPFLICATI019.000{4113) <br />