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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12 / 2,-Y;� OFFICE USE ONLY <br /> To: San Joaquin County JOB# //ZICxi$"' REF# <br /> Department of Public Works APN CR# <br /> j EXP. DATE �"ah, fS, 2,0ill <br /> See�/, ��� { VALID -T s, 9T0 TitM, /���s,o4 DRIVEWAYS: <br /> (Applicant Name) STREET WeJ144 , <br /> (� C AREA j,' QUAD Sw <br /> -0 \A,(/\ SLA7 TYPE <br /> �J Ca„ ! (Mailin Address) FORMS <br /> f�Ct <br /> V C C , C� ��L{(� j 7 NOTES <br /> (City, State, Zip Code) <br /> 71Lt!S <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �� IOC4���,y� �� �� c7•� ��f��� Si`� �ff' <br /> E <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High Right-of-Way on <br /> the side of approximately ile Y}or-th <br /> of �t " t/Cz> 1, Cts , by performin the following work(description of work): <br /> SAI C W i 1} '41j 1 One l ►.�(6, S. 0 <br /> t �i n� i � A '_NL4V, � � � O pac_- ''1 O'-dc' <br /> coIle <br /> C+ I �v SST 1A1 Ail 1451 <br /> -- �� eta s drr ► ✓� . tdllo;.i�Yr,�rl- C 0ec4&A J r,��:-,-� l�yJl �r <br /> Work will commence on or about_�cr_ int '201 for approximately i '/22 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 /> Signature of Applicant-Title Date <br /> E:,PUB-SV.WI6MASTER.PSIENCROACHMENT PERMIT APPLICATION.001; (01(08) <br />