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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9-Z 3 . ZO/U OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 7 /t <br /> t.,Jond brid qe, IrYigar1oy� V 15+r;C1- VALID TO ? / // DRIVEWAYS: <br /> (Applicant Name) STREET nd ' 1Wr ,�. <br /> AREA dtboa66r► QUAD _ <br /> .1972-7 A)ovit, Lowey Sacrayne Ao Foc,4 TYPE <br /> (Mailing Address) FORMS , Z <br /> NOTES ��— <br /> („ nedbrid a Cf- 96-2-69 <br /> (City,State,Zip Code) <br /> (a09) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See o-Wa.46ed ���cuisJ <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 feetimile <br /> of , , by performing the following work(description of work): <br /> ai a/ict, �S�rer�/'4 o�fl, LouAv <br /> Work will commence on or about v for approximately 7=-1=i0 days. <br /> 1,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 /> ZX��� 9-23-aow <br /> Signature of Applicant-Tithe Date <br /> E:IPUELSV.WK%MASTER.PSVICROACHMEMPEW.ITAPPLICATION.DOC (07)08) <br />