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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7603,10 REF# <br /> Department of Public Works APN CR# <br /> • l EXP.DATE 'a d� <br /> r 1 V _Qi <br /> -5icG U0 el VALID -� TO Jai p DRIVEWAYS: <br /> (Applicant Name) STREET ., r�, <br /> AREA .Coal- — QUAD <br /> ZSOo ��+ li(/� TYPE _ g46: e_G rTi7 -"pnk <br /> (Mbiling Address) FORMS <br /> SNOTES 64rrll <br /> o ibn �a l <br /> _2C67 <br /> 67 a far✓ ,crr <br /> (City, State, Zip Code) <br /> 209 _ 737- 697y r �� <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> P1a A a lld <br /> The undersigned hereby applies for permission to excavate,construc and/or otherwise encroach on County Highway Right-of-Way on <br /> the_ i.✓eS side of Lo(,,-e, �G /t, r1�0 j/ approximately_ feet/mile ✓o�� <br /> of�' � n`(e A by performing the following work(description of work). <br /> Work will commence on or about b 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 /> Signature of Ap, flcant-T' le� to <br /> �} � ' '�— Date <br /> MOPU'>i tEa?L4rE9Ei�LFG�C1't.tE;,i Pe'9��dR nPaUCn n2i H,rCu[2) /J <br />