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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT, <br /> Date AuWt" 1is OFFICE SSE ONLY <br /> J <br /> 70 <br /> San Joaquin County JOB# X X C.< 5� REF# <br /> Department of Public Works APN 019# <br /> EXP,DATE (0-I 2-oc)!j <br /> 6ti,14J, 10VALID 9^ 20 (t?-1-220 DRIVEWAYS: <br /> (Applicant Name) s STREET <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> L C� 11f,11,-AVA <br /> �Ij- <br /> The undersigned hereby applies for Permission to excavate,construct and/or otherwise encroach on County Highway Riont-of-Way or <br /> the side of approximately feet/mire <br /> 01 <br /> by performing the following work(description of work): <br /> W541(t CAA 4CIA'IretZ c A 4),a, 1� <br /> 02 i'lj Waal <br /> '�k 'kyes!s&'A� 2L%V je.'L� <br /> key hvj!�g " --c V, <br /> Wky"Ira's AKS 4MY15 <br /> VVork will commence on or about <br /> eot t5 ico. for approximately 4�yu' days. <br /> C <br /> 1, !`e undersigned,certify that i ar-., the owner of the respective property,or am qualifiedepresent the owner and agree to do the <br /> to, I <br /> work described above in accordance o,64h the rules and regulations oll'San Joaquin'County and sub;ect to inspection and approval. <br /> -Srg—natdrie of Applicant-Title Date <br />