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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date {G- 2-VF OFFICE USE ONLY <br /> To: San Joaquin County JOB # ?360r? i�3 REF # <br /> Department of Public Works APN CR # <br /> y/ EXP. DATE ?� \�.ka <br /> p TT r� �/oS� C1 tl^�-�an <br /> VALID \-M- TO DRIVEWAYS: <br /> ✓� <br /> (Applicant Name) STREET MAe-Srj 4E, * <br /> f2J PE C U <br /> (Mailing Address) FORMS —T— <br /> / '73-21 <br /> NOTE <br /> (City, State, Zip Code) <br /> r <br /> 41 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> r 5-u 2K <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the - j vA side of <br /> /� approximatelyy �o feet/mile <br /> of tt,?F(�n y t/ 14";-4 �nec�iv� by performing the <br /> following work (description of work) : 47rP`eec Cr�,.�c/ /tcs� {'% £ .sl,nt i�k'�&L ,r <br /> 'Y,/J� <br /> �r/�cc zs'x % ons G� ,pcd it»c 5 Conf,,.iSowg <br /> 1/o <br /> , fr.�r'P.� G✓Jl� fjr /.nr�.r�� OY' Ci��flJ /V// <br /> 'f dal'J Gi°rt1 �✓l� fir C�r7c� <br /> work will commence on or about Tom^ /0 Z010 for approximately <br /> 60 days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the o-A er and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applicant - Title Date <br /> :ASTER..FS`,_cES•_!iT_ �- <br /> Ty !v�es�u�, •{�.- V oa h �1 inn <br />