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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -3 dam- 10 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE I�r j1J <br /> Z; VALID o TO /5' DRIVEWAYS: <br /> (kPplicant Name) STREET UGITD, .rTfi9J Pity <br /> AREA &AD _ <br /> L-15go QAUF AS k,, TYPE PES �P� <br /> (Mailing Address) FORMS TTS <br /> NOTES <br /> sio-,ksrvvv e-A t�5ay� <br /> (City,State,Zip Code) <br /> loaDl 3 33-6185 <br /> —� (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the r..T- side of f;;RZ� approximately ile WEST <br /> ofdont,-4,,Al X-dt�SE'' E'.+✓ /' by performing the following work(description of work): <br /> ZZeE rZQIA F-21 s7`r�A14L* 6--ATV AU(-T- sW A44uti -j A1At buss pxw r -�'r5,x y I, <br /> �-6C-#4U re i2�. L NSTA1 i. 4 S- e ✓Aut-rs 4jgi> - l�Ml)y'�e'TS� .rFV0,1AyW <br /> as 1 ' CCS . TO 6e CA'T✓ no t rU se—,NL41,T15 -Rb <br /> Work will commence on or about_ q--5- i© for approximately ?g2 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 /> Sig u o ppl cant •Title Date <br /> i".PUS SV VVKMASTER.P$'.ENCROACRMENi PERMIT APP,:CATION (31,2) <br />