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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date `i`Lv� © OFFFICE USE ONLY <br /> To: San Joaquin County JOB #1REF # <br /> Department of Public Works APN CR" # <br /> EXP. DATE ` C^2p In <br /> A77 VALID - TO I -2<:)In DRIvEWAYs: <br /> (Applicant Name) STREET A iVr <br /> AREA QUAD <br /> 2300 L- 1Gt/,% e iLi- A'dJ TYPE <br /> (Mailing Address) FORMS�� ) � <br /> NOTE <br /> t., Tu K?ti,y <br /> (City, State, Zip Code) <br /> ?oy <br /> (Area Code - Telephone Number) <br /> Sketch y�(Detailed {plans may be submitted) <br /> . z 0<-X 110 OM6 676-4 Ttxt-/ <br /> 5/,0e Ccs�'Syl�Cl6'1[xtJ. <br /> Z I Z <br /> Zvy r AAvrC'sL)s- 1J.A Z,<(7 lot 5X7.ucAoz, <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the -504. tT H side of <br /> G�JA�N/�!%GToAJ approximately 6-0 ee /mile L`.4 7 <br /> of iEKbS , by performing the <br /> following work (description of work) : e46' eta£ 4AID 0,1 ffiICiA/c <br /> TKE.uetJ .z u 5-EyEe4(- CL u0v17-r P14CC CuZ(1CC-r P/PC- AJ40 f4aFlc[ g-1/;r# 4640 64 <br /> A4-so 1'l/1C our co caw T 4" ��« B �Ci Q Z �/ �170 < <br /> All twiOe cA A C-r- goclL c)FF Kd.4Dkj4 3e: j✓o ���s s Bc cc.�I'D, -- <br /> Work will commence on or about �G"`1 .1 zoto for approximately <br /> 40 days. <br /> I, he undersigned certify that I am the owner of the respective property, or am <br /> qualified to represen.: the owner and agree to do the work described above Jr. <br /> a.^_ccrdance with the rules, regulations of San Joaquin County and subject to <br /> inspection and app oval. <br /> Signatur4 of Applicant - Title Date <br />