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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• " <br /> Date w ✓ OFFICE USE ONLY <br /> To: San Joaquin County JOB # /1406' REF # <br /> Department of Public Works APN CR' # <br /> / EXP. DATE <br /> �,tiwr• r'S ��S�c �cas'. r1c �c'wllS 51VALID 0 TO DRIVEWAYS: <br /> (Applicant N e) STREET �/LY1S S <br /> c, -7 / L AREA tcrd��o QUAD �— <br /> J/ 3 / TYPE ?tel)JCH) <br /> /1(Mailing �Address) FORMS STS t t W) <br /> NOTE <br /> Cityy, State, Zip Code) <br /> m� �r 2c?5 iii-oS/� / <br /> 2.dZO (JiiSa7� <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> l4 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately feet/mile <br /> of by performing the <br /> following work (description of work) c/ e>, 4 <br /> h���( /�z C'O/<7���C�'r✓J G✓' l -!t'C C Ov.'1� /yrs✓/�jr,c'/�1 !/O' <r /.< /ti C_l'[',/�'r /®tY,L ..'oC✓/.� <! <br /> { a„' tCF /-I✓!E C/�S t" /(�1✓/�� , �''iG'Cr� /C OC c� !-L F-'rC rt^ Lt/// Jf /4/,C h ! </!. <br /> 37 <br /> �'S T<<-✓�<, +c l �C�O C'+ 7"�nl h.n /1 NCS' <r !O<�: I.PSCC S �L P�� `t�.'Ir✓rrr tJ r C�.�� /<"r<vr✓./ ,e..lQ rr-o.-�.<.,� <br /> Work will commence on or a out for approximately <br /> a 7 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 /> z"I- <br /> S" ature of Applicant: - Title Date <br /> / STER.PS\FEESCHDL (6/00) <br />