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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:RI <br /> Date `- ,�)' n OFFICE USE ONLY <br /> To: San Joaquin County JOB# �d1 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> R OSS CoRaut.L,���C VALID TO /i-Ir-0 IF DRIVEWAYS: <br /> (Applicant Name) STREET ��g/lj,� "&. <br /> $$'13 IUyRNER`� \-Lic. Rd AREA B5coW,A4/ QUAD <br /> TYPE - igfG,c mac_✓�C <br /> (Mailing Address) FORMS <br /> ORIrcJ41e- , C^ 9531.E NOTES <br /> (City,State,Zip Code) <br /> c2.09 s4t - SgSg <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> SEE R etic.he Z RA!Ft i C <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of_ approximately feet/mile <br /> of , by performing the following work(description of work): <br /> Sea - up Foa Rzsn,3 \ iR�ptocFr�en-� o\©moo <br /> _�Z-etwcz Rd. <br /> Work will commence on or about Ct a$•pot for approximately S days. <br /> I,the undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> e.Ni EF ES��Mq�'4C �• 1$• 0� <br /> Signature of Applicant-Title Date <br /> E.IPU&SVWK"STERPSIENCROACHMENTPERWTAPPLICAIIONDOC (01M) <br />