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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> C� OFFICE USE ONLY <br /> Date -,S .1 <br /> To: San Joaquin County JOB# r REF# <br /> Department of Public Works APN CR# <br /> {{ p EXP.DATE <br /> 1 Y`1 LCj 1 e!1L DRIVEWAY <br /> VALID TO S: <br /> (Applicant Name) STREET <br /> C.� AREA <br /> ( I <br /> Y-)co I Y`\ to i? TYPE <br /> (Mailing Address) FORMS <br /> r, NOTES <br /> 'S�z <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pians may be submitted) r <br /> L; Irl <br /> V% �� <br /> Vi <br /> Nor4F \ V <br /> I <br /> r <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the NoO,h't So,, side�.j c s - ruin ffid, approximately ( B o� feeVmi e -�(bM <br /> of�-Je-ft)t q, P/qct _ vent,) E by performing the following work(description of work): <br /> u ;L s e -kf- L!V aG ' evfed <br /> -- <br /> rr���uu fA <br /> oart <br /> Qcl rr� c gbh d <br /> Work will commence on or about '7 a�>O c4 for approximately -4ays. hkVtr <br /> g�1,the undersigned,certify that I am the caner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordancewith a rules and regulations of San Joaquin County and subject to inspection and approval, <br /> ignature o Applica ate <br /> _•.PU65J WKJfA81EP_BENCR�:NNENT°EPµr AOaIKA'CN.UCKIglittl <br />