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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: GU id N U <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB 9 <br /> REF# <br /> Department of Public Works APN CR# <br /> EXP,DATE <br /> k� <br /> VALID TO DRIVEWAYS: <br /> 7- <br /> Tr7 <br /> (Applicant Name) STREET <br /> AREA Dp/-foi QUAD <br /> TYPE 41 <br /> dw-,--/ -061-p I <br /> (Mailing Address) FORMS <br /> ffz�- at l9k,/9 <br /> "/] NOTES <br /> (City,State,Zip C6de) <br /> 9&0-----ire (0- <br /> (Area Cade-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Rjght-of-Way <br /> on <br /> the 06,�5j -t&:5�- side of IV feet/mile <br /> 7nlein�,WAE-1 ',�- /42tr5,,, ?,,,,fapproximatefy <br /> of <br /> by performing the following work(description of work): <br /> 10" will Ale 1'e Air) <br /> t0 ,Il kv <br /> 10V Mo 1?- <br /> Work will commence on or about 1 E i ` �: (� <br /> for approximately-..... I X19 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 above in accordance with the rules and.regulations of San Joaquin County and subject to inspection and approval, <br /> F1 <br /> Vrtlur? f�A�p6pli��t-Title Datd <br />