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APPLICATION FOR ENCROACHMENT PERMIT <br /> pLEpgE PRXNT: <br /> . 320 Ao � 0MCE USE ONLY <br /> pate <br /> To San Joaquin County JOB # //a D REF # <br /> Department of Public Works APN CR <br /> EXP. DATE <br /> "Pe e-i��7$e6's VALID `f-`)-U/ TO "l.��/ DRiV$pPAY9: <br /> (Applicant ame) STREETf1i Iss IeA/ 4IIE � <br /> / ARBA cDZC�&--Ta QUAD CSC- <br /> /�,f� GsylPi� TYp$ 4t0All7-,0k1,c/6 <br /> / (M/ailing Addrees`s/)� FORMS SS/ct'k✓ <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 9 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the 7e— side of <br /> i approximately ep,s _ feet mile .S�cr <br /> of :5A2,no r44r d . r oA, performing the <br /> following work (description of work) "ifr <br /> G✓ ✓ /• ,.. <br /> .� ..R Ile— <br /> O Imp f" <br /> e. ♦ •- a- 095. <br /> '� .H f 7Y7 <br /> Work will commence on or aboul f3r approximately <br /> days. <br /> I, 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 /> Signature f Ap 1 ant - Title <br /> r�Tn Psknuscm L <br />