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t � � <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Ju-WI .'. OFFICE USE ONLY —1 <br /> To: San Joaquin County JOB# REF# _ <br /> Department of Public Works APN CR# _ <br /> , A EXP.DATE i ,p <br /> N,of—)r' ��M� �1� s VALID f i TO !d 1 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 1°J1 1K)C kt7 e l6 t n A V'f TYPE �1,rld4 , <br /> (Mailing Address) FORMS <br /> yzlw <br /> NOTES <br /> -Or&kdo le Cri 915 D I <br /> ✓"r 10.�1' ./IJP .s <br /> (Cit), State, Zip Code) <br /> CPO?Y4R- nILoC - _IQ ir-0 ViS - <br /> (Area Code,-Telephone Number) <br /> Sketch(Detailed plans may be submitted) -- <br /> L <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the s�-5tf! CA A+GL Ja Y15 approximately <br /> approximate) <br /> of y feetmile <br /> 1.ri5-4 t lOt#��,r1 C by performing the following work(description_ of work): <br /> n <br /> tt_m Pie e1rrt rj@ ars \ -reP i' <br /> Work will commence on or about_ rn�- for approximately t <br /> _ 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 /> )gdrmin Rist 1 <br /> Signature of Applicant-Title Date <br /> c 1PUaSV WNIMASTER PS%ENCROACNMEfJT PEAMI T APP,,CATION f10C (01/08'. <br />