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APPLICATION FOR E-NCROACHIViENT PERMIT s - y <br /> PLEASE PRINT: .,_ 1, (� •�', 5 <br /> OFFICES fg�E'ONtY ` y• <br /> Date <br /> // S� <br /> To: San Joaquin County JOB# REF#APN CR# <br /> Department of Public Works - <br /> EXP.DATE DRIVEWAYS: <br /> S VALID I�2(�-Ili <br /> Name) STREET Lt?Ct' 110`A <br /> (Applicant QUAD K Gt/ <br /> AREA 'G <br /> z7 f 5�I S1� ST. TYPE AUL 11VSfALt: <br /> FORMS 'Z <br /> (Mailing Address) NOTES <br /> L /vt-o 1 b Gl4 u� S SCU a tr d J4L?" <br /> (City,State,Zip Code) <br /> z s17 77 <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 HighfeeRi eht of Way <br /> i on <br /> �t 0 F.- to side of LO t G c L)A LI �?- approximately <br /> the, ct V-To _ by performing the following work(description of work): <br /> of-"f 4O/-E6 -i?-1) <br /> j FrZvr�" .`CtST iJ� V C. TvyqLI�r To <br /> E � Wi ;,u�l►�� �1��- <br /> C-C>&-)iti1A 1:[ c ? S.& C <br /> Work will commence on or about iC� i -,- " 1 for approximately c� 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 /> ignature of Applicant-Title Date <br /> MiCENTRALSERVICESICLERICAUPU&SVNKIMASTER PSIENCROACHMENT PERMIT APPLICATION DOG (09113) <br />