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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3 ^;,) -O-!(3 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# /IAW6` REF# <br /> Department of Public Works APN CR# <br /> CY6r4hsrl. <br /> s .Xa4e r5 VALID ATE <br /> u- -3-/30 <br /> a TO S ' DRIVEWAYS: <br /> (Applicant Name) STREET ,pp C.41")Clj� <br /> rr__ rr AREA M(��q QUAD <br /> CLQ ' <br /> a (.-7 q TYPE <br /> (Mailing Address/) FORMS 55 -►L <br /> gi-07 (j NOTES <br /> (City,State,ZilCode) - <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies.,fpr permi i to a cavate,construct and/or otherwise encroach on County Highw Right-of-Way on <br /> the E4S-t� " side of '4(ak-�e roles approximately <br /> � _ f bOQ mile <br /> tuts 0� , <br /> Of �� CL �E+'1rC�''1 ��i.r►TP by performing the following work(description of work): <br /> �a5+� <br /> a i !of u otzn ' 1 - In f e r <br /> !0- b - �1 -7G. <br /> Work will commence on or about 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 rules and regulations of San Joaquin County and subject to inspection and approval. <br /> --- 3 aq <br /> Signature of!Applicant-Title pate <br /> EWU98V.WIMy.STECf Pt*mCROACNMMP!RMYAKILiCAT"LOC 4010) <br />