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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: p <br /> Date //o - Z J - D 9 OFFICE USE ONLY <br /> To: San Joaquin County JOB# owl-a REF# <br /> Department of Public Works APN T CR#,. , <br /> � EXP.DATE <br /> Vel-17- ig rI Ca//za n/Q 1/lam . VALID TO _/.�p1D DRIVEWAYS: <br /> (Applicant Name) STREET t <br /> AREA-43L C ter TYPE +-WA QUAD <br /> (Mailing Address) FORMS <br /> NOTES <br /> /� le-c 3310 <br /> (City,S te,Zip Code) <br /> 209 - 23 9 - 0334 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersign hereby applies for pe ission to excav te,co struct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of y� ,,�///ter o�d approximately /75 feettmile e!-Q�4 <br /> of r by performing the following work(description of work): <br /> Dig/ 0,4 �i� ,�i�✓c%e�/"O �/�y <br /> ?7 do / <br /> roM d /fA A <br /> O G i vo �L/ b°n os �G VC• o '' /eft►. <br /> Work will commence on or about f/- 23-O 9 for app oximately O 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 /> .Z9_0 9 <br /> ignature of Applicant-.Title Date <br /> F-iK$,WWMIMASTERPS%ENCROACHMFMTPaWAPPUCATKXDDC(010) <br />