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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (p Iq-�� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> �•�• 1 n VALID �•2•i.o8 TO (- I•o DRIVEWAYS: <br /> (Applicant Name) STREET �,cy-o�� <br /> AREA 9SGs9Laxl QUAD 15:6(d F I-4 I cn 11.4W aY I Zt7 TYPE �"tZE ► <br /> (Mailing Address) FORMS <br /> NOTES <br /> I`'t AIJTi�c.�, �A X533 Co <br /> (City, State,Zip Code) <br /> 44to 40 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> o <br /> II�11 �4 sr� . wY <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the No K•TK side of H 1 yH"A-f IZo approximately 3�000 '! feet/mile �.IviZtH <br /> of THE H cr,H bu,c.-{ , by performing the following work(description of work): <br /> " .IZ.�.* ��. �QR�G�TiaJ <br /> I�l ��ca PST S��t-rota fes. <br /> z 1,,.r-.• R-fa.R.G.P. GL IV I fdI IbAM-924-4 t.R0101v t4b AWT t-,c.W i Wl..� r p. <br /> —411tvP 4Z'' Iz.G z c.E Gt- IV I rtFj4pTbQ c g!064l jtn AT P E�•�tt <br /> Work will commence on or about for approximately days. <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 /> (0 ( 14- 10Y <br /> Signature of Applicant-Title Date <br /> E IPUB-SVWKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC plw) <br />