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APPLICATION FOR ENCROACHMENT PERMIT 20'11K31V ?X1 : 29 <br /> PLEASE PRINT: ;c.r .i " ; Y�`G t;IS <br /> � . _ . <br /> Date )�[ i OFFICE USE ONLY <br /> To: San Joaquin County JOEL# Z ry 0 2- � REF# <br /> Department of Public Works APN CR# <br /> (,��� EXE'.DATE _ <br /> B1 GCGk 1�171C'71, Coin SLI.` 'J G VALID -I TO J2 -( DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 24Q I 'a-oa "rY%,Ar\ Ave . TYPE <br /> (Mailing Address) FORMS <br /> NOi ES <br /> West Sczcr'arnei2YCA 9Sb9] <br /> (City,State,Zip Code) <br /> qtb� -375-Y7o(o <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> -;>1+ ' Oar\ o_nJ_ "t'Y'2". C_ rYiGu-1c�C�Me{�t 'h�G.r1 S 0.�tccCh2 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Nor'+-hI5outl sideof UJ Ai jnda 'RUacd —approximately n,% fee ile)� CcS-I­ <br /> of S, a-a c k±one RA by performing the following work(desc,ription of work): <br /> X1MI-AIMIFIC <br /> Work will commeficelon or about NOV 3b DoG. I C) for approximately ! 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 les and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant- e Date <br />