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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT- <br /> Date Z OFFICE USE ONLY <br /> To: San Joaquin County JOB #_ '�'3c�'7� REF # <br /> Department of Public Works ppN CR # <br /> EXP. DATE _ fU•,�a <br /> � ����� '� <br /> VALID. TO �G:/•Oe� DRIVEWAYS:. <br /> {Applicant Name) <br /> AREA <br /> a�� 'c >�cset�17p.D <br /> — <br /> � ® x�Y. �WW� TYPE <br /> (Mailing Address) FORMS <br /> NOTE . <br /> (City, State, .Zipr Code) <br /> C -1zR %2t0 <br /> (Area Code - Telephone Number) <br /> ------------------ <br /> Sketch (Detailed plan may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on -County..Highway Right-of-Way on•the <br /> of approximately feet/mile <br /> �- by=per€orming the <br /> following work (description of:work) : <br /> ' N`A1N St�►�•CA � RT��h� -,��S � t'4F'�Fc,� MAIL SUNI'�A SG�AU.. 1y10 OF . <br /> e.9es� ° <br /> 6 <br /> K 14 <br /> Work will commence on or'about _ AVE \h111L R( A <br /> Q �� for approximately <br /> days. t'10c� <br /> I, the undersigned certify that I am the owner' of. <br /> qualified to represent the the respective -property, bam <br /> � <br /> owner and agree to do the * descried above in <br /> accordance with the rut s, regulations <br /> 'of San Joaquin County and subject to <br /> inspection and approval' Pq 49: <br /> Signature of Ap?la.cant •- Title ' <br /> Date <br /> MASTUR-nkm CWL <br /> . i <br /> 4 <br />