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Apr 15 10 02:26p LPFD 2098872821 p.2 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# j/leo 6 REF# <br /> Department of Public Works APN CR# _ <br /> / EXP.DATE <br /> Lf►luACty-- t;'"Ft�2�u +ll�:r32 U,�C2�w� .Y14. VALID S'?tii TO S' 20 Xi DRIVEWAYS: <br /> (Applicant Name) STREET . <br /> , AREA QUAD <br /> ^� TYPE ` .�E�Ti✓i9L <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 3`710 v�c- S:,,. , <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE 4TTIA-CAcn <br /> i <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the-,&r4"4 side of_ F/2 o k3 y- approximately feeftle <br /> Of by performing the following work(description of work): <br /> �C-l�5 r'✓>� o� �ii�- S r d3�7w��r� ,i1?�k�-7' ,�T v�. 7�- �=�s% yip <br /> Work will commence on or about r 1 S, o i 0 for approximately g 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 Ap t-Title Date <br /> rnesiaxw.vsh�.vsFncao�c„uee-PeHieira�ca-:o.occ mi�� <br />