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APPLICATION FOR ENCROACM= PERMIT <br /> p ,FASE PRINT: <br /> Date OFFICE USE ONLY <br /> To; San Joaquin County JOB ; //b b _ REF # <br /> Department of Public Works APN CR' 1 01:5 6S-7- <br /> EXP. <br /> 5-7- <br /> EXP. DATE /3 d <br /> �Z _ _ VALID Y-"01 TO DRIVEWAYS: <br /> (Applicant ame) STREET 441,5X00 1 AVE a <br /> AREA STaC1 i o QUAD Cc- <br /> TYPE TYPE 4,feta l rope /Altar G✓&ZL <br /> t (Mailing Address) FORMS <br /> NOTE <br /> (City, Aate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �Ce 1,"77-0;,n e41 <br /> /OG cu.�s �u••r�• Ci7!/i�0��lPy?i/ <br /> 9 • 7,42 <br /> S/fooz y <br /> The undersigned hereby applies for permission to excavate, const ct and/or <br /> otherwise encroach on County Highway Right-of-Way on the ec side of <br /> % ioh " approximately �eemile <br /> of -�i e- SGtJ /b�iy�r' o A IVILMo -G�r�.s�..iC LS performing the <br /> following work (description of work) : r. : ✓ o40 r <br /> or 4P <br /> .2ra��ef <br /> d r <br /> Work will commence on or abou /for approximately <br /> .. 3 days. V <br /> 1, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signat <br /> Dae <br /> a o£ App icant - Ti a <br /> M.45nR.AS1FYLSC�L ff/70/0x1 <br />