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APPLICATION FOR ENCROACHMENTPERMIT <br /> PLEASE PRINT: <br /> Date oFEICEUSEONLY <br /> To: San.Joagjin County JOB# REF# <br /> Department of Public Works APN GR# <br /> . EKP.DATE /^ <br /> A!G"PCA'0 k US jc . VALID / 0 i // DRIVEWAYS: <br /> (AppkahtName) STREET �k �Soir/ BDA. <br /> AREA . e .QUAD SW .. .. ' <br /> .(Ma'I Aodress) F i <br /> NOTES <br /> (City,State,'Zip Cade) <br /> 75 .3f <br /> (Area,Code Telephone,Number) <br /> Sketch(Detailed?p:ans maybe submitted) <br /> The undersigned:hereby,applies forpermission to excavate/?,construct and/or otherwise enproach on County,High%ay Right-of-Way on <br /> the -5a 2% side of -5. hi.�o i2rs approximately cryo mile Avst <br /> of -z�,b /e le ..faro by performing thefollowingwore{despdption of work): <br /> -J64 VaP l �" is epi <br /> D/[ <br /> Work will:oommenceon orabbut forapproximately 62.' QVAom z"j days. <br /> 1,the undersigned,certify that tam the owner of the respective-propgrty,oramqualif edto represent the owner and agree te'do the <br /> work described-at ove in accordancewith the rules and regulations of:San Joaquin.County and sublect,to.inspedoni,and approval. <br /> Signature of:Applfcarit-Title Date <br /> ewue:sv.wkM+s�en.Pg�nC�HeryY,ffwuteeR;amx4bc N+�i <br />