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APPLICATION FOR ENCROACHMENT PERMIT- <br /> 'LEASE PRINT; <br /> Date ,fV ,% OFFICE USE ONLY <br /> i <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN 0r'L``' :` 2_ CR# <br /> EXP. DATE t Z <br /> a-1,4 LUGC fS VALID TO 2 -1S--G DRIVEWAYS: <br /> (Applicant Name) STREET . t <br /> AREA mac, 1�.rFc1.;;,PUAD <br /> L DA+ 1i ( TYPE t <br /> (Mailing Address) FORMS t?,2 <br /> NOTES <br /> (City, State. Zip Code) <br /> (Area Code-Telephone Number) , <br /> Sketch(Detailed plans may be submitted) �E <br /> 1 <br /> ,g{.. 7— i <br /> b' <br /> 'he undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Higher Right-of-Way on <br /> ie _ mac, Tit side of A&46xLSW7approxirnate y ,-3 is 7` feef/mile <br /> f by performing the following work(description of work): <br /> JoriJrii commence on cr about tics, for approximately days. <br /> the undersigned, certify that, 1 r `9 owne,of the raspecf've prose iy, or am quaiifiec to represent the owner and agree to do the <br /> 'ork described above in accordance 'Jith the "u'es and reguia icns of Sar,Joaquin Count]and subject to inspection and approval. <br /> f' a 3 .� <br /> S' nature of Applicant--Title Date <br />