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APPLICATION FOR ENCROACMXT PERMIT <br /> PLEASE PRIX <br /> OFFICE USE ONLY <br /> Date <br /> To: San Joaquin CountyN .O�eR� 4 — <br /> Department of Public Works ERP. DATE '� �l�"`"_' <br /> Tp DSIVEWAYB: <br /> U�fG L�'EvO�•S (xtw > VALID Y <br /> (Applicant Name) STREETAREA QUAD <br /> TYPE lzJ� j <br /> (Mailing Address) FORMS <br /> NOTE <br /> \1a We , CIA �537� <br /> (City, state, 21P Code) <br /> -�o-c\ <br /> (Area Code - Telephone Numborl <br /> Sketch (Detailed plana may be submitted) <br /> cJ� VkR"C`AC�rtG?) <br /> applies for permission to excavate, construct and/or <br /> The 'undersigned hereby p. aids, of <br /> otherwise encroach on County <br /> y- Highway Right-of-way on +aE <br /> approximately U�''F fee mpile <br /> pp i �A Nccv� J &�Y Orming the <br /> r� [� , 7 C <br /> o£ <br /> following work (description of work) : <br /> for approximately <br /> Workwill commence on or about <br /> days. <br /> Y, the undersigned certify that I am the owner of the respective property, or am <br /> to do <br /> qualified to represent the ownerregulanonego£eSan. JoaquinwCounork ty and subjecescribed t to <br /> th the <br /> inspection and approval. <br /> Yin Date <br /> atura of App <br /> ca Title <br /> IM9lN6.es\PSEBCINL Id/sol <br />