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F APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2'-z / I b <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# tlp00'=;- REF# <br /> Department of Public Works APN CR# <br /> I � EXP.DATE 3 a IaLol0 <br /> l-fo�,1 2e�� IJ ""r^ �7 s 5 1"Ic VALID <br /> � <br /> (Applicant Name) STREET c�03� TO -r m la DRIVEWAYS: <br /> `� fro�! OIL ve. <br /> AREA QUAD ' <br /> TYPE CP-EmQc t8L <br /> (Mailing Address) FORMSr,+.Ou ,o ate, wEti� <br /> NOTES <br /> �Scaleh C_ 95320 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be s bmitted) <br /> F � <br /> � ` o <br /> g <br /> 1 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the e,ckS-- side of_wj, A�g� FrMLug RA e&,;�approximately l S fee mile nr o rf c <br /> of__ 0 l tQ�e n rcg,, e ca by performing the following work(description of work): <br /> e5�''� �^ Mw.: w:.. ill M� ,res v.�- vo✓�-,`.� w:� <br /> G�✓p �� Ana AUP/d r �� Dl3l� r l,� lZ 1n ✓A-Rc+ 27^ F+t4 <br /> z � e <br /> Work will commence on or about A} e���a�� for approximately da s. <br /> Y <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 1,�� ' r <br /> V � S�-�FF G-20 jo r '1`` <br /> Signa r Applicant-Title Date <br /> EAPUBSV.WNWASTERPSENCSOACHMENT PERMIT APPLICATION DOC(01m, <br /> i <br />