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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:: 11 <br /> Date 419/0 6 OFFICE USE ONLY <br /> To: San Joaquin County JOB # (loo < REF # <br /> Department of Public Works APN CR # <br /> —I E%P. DATE <br /> VALID TO DRIVEWAYS; <br /> (Applicant Name) STREET4eLI TDI-. <br /> �r ft / /� AREA Sl'ou�cou QUAD I.V <br /> P©'-�P S4 , <br /> I1 ' l I Y l h ROOI 1l TYPE {o2F <br /> (M <br /> ailing Ad/ .�y <br /> drel/ss)� FORMS <br /> /✓I 'e.r( yV u �l•�. <br /> C4 <br /> ! 15 ?� NOTE <br /> City, State, Zip Coda) <br /> (, Se:� - 'ASDD <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed planes may be submitted) r� <br /> The undersigned hereby applies for permission to excavate�{,11cone-truct and/or <br /> otherwi a encroach I ont County Highway Right-of-Way-on the PA C4+ y So d, side of <br /> WA sl a n H' 1; 6r. approximately feet/mile <br /> of I I , by 'perprming the <br /> following work (description ofr work) ; <br /> Work will commence on or about for approximately <br /> S 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 /> Agnature <br /> ance with the Les, regulations of San Joaquin county and subject to <br /> tion and appro al. <br /> ". � n <br /> of App13c - Title Date <br /> IYMOm(. 16/001 <br /> I <br /> 1 <br /> 90/E0 39Vd SlIw83d ODCS VZE689V60Z BV:91 900Z/E0/01 <br />