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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEA tl:)KINT:` <br /> Date l ^ J OFFICE USE ONLY <br /> To: San Joaquin County JOB# , �'�'0 5� REF# <br /> Department of Public Works APN CR# <br /> ��sr- /` J EXP.DATE L !s !f <br /> S �Lo / C tl (e-)S -,r- ►f VALID TO > - 15 /Y DRIVEWAYS: <br /> (Applicant Name) STREET y F r� <br /> AREA QUAD 1Y1 0,- <br /> C/o srf-4s 4 TYPE <br /> (Mailing Address) FORMS <br /> � <br /> L/ <br /> 11&040)0l , GHQ 94 550 NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies forpermission to excavate.construct and/or otherwise encroach on County Highwav•Right-of-Way on <br /> the646-1c,O&Si side of l/uT 66 rfh approximately eet/ ile Oc.�l �l <br /> of �"TCc��0 0 by performing the following work escriptio of work): <br /> Work will commence on or about i 0 -- V9 IS for approximately 7- 2 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 /> 9 2s- 15 <br /> III" <br /> Applicant-Title Date <br /> 11111 T111111111EMIM DIU%&SV WKIMAS111 RSIeKRDACMMIII PERMIT APPLICATIII NDOC (09113) <br />