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S <br /> APPLICATION FOR ENCROACT PERMIT <br /> PI,EASN PRINT <br /> Date ` /3t t /0& OFFICE: U= ONLY <br /> To. San. Joaquin county JOB REF # <br /> Department of. Public Works APN _ Clypap. DATZ 3 1 loC. <br /> VALID-. • TO , a$rvs�Ys:= <br /> (Appiieartt name) STREET pwyyqE. F�oM'.a�,E ,eu #jd,°Pmli:�liv.' <br /> v& TYPB <br /> (Mailing address) FORMS. Js uxJ_kLZ9 <br /> CA . � �'# �G$ NOTE <br /> (City, State, .Zip Cade) <br /> (Area Coda - Telephone Number) <br /> Rt s''PG.075'3 <br /> Sketch (Detailed plains may be submitted) Q cn <br /> M <br /> U c D <br /> -� C z <br /> n 3 C7 rr, <br /> C <br /> 0 <br /> ' �v w• z <br /> cn '� <br /> The tznder-signed hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County-Highway Right-of-W�y .os . a7id +�f <br /> -Phe_ f Frrr apptoximaatel 8 feet/ e ►1arw o- SoJ4, <br /> of . r )A <br /> following worx (description of work).: <br /> ov. <br /> Work will couune ce on or'about, frib��� <br /> (e� 'd.00 6 � for approximately <br /> IS days. <br /> I, the undersigned certify. that I am the .owner of the respective property,. or am <br /> qualified to represent the owner and agree to do the work described above in . <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> x/3110 <br /> signature of Applicant - Title Date <br />