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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date LQ 7/1 b OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE �, �� �� <br /> O SCS r VALID 0 0 =k41 <br /> ---- DRIVEWAYS: <br /> (Applicant Name) STREET —�E-AC &-Vp. <br /> AREA QUAD '5M.) <br /> I 7 4 C I LJa•n TYPE -I-PA Ac- -T Tcj').e IA1-Kth ' <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> --- C) - I4 a --1nZ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S'(�— a'+6'� <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> t�- vside%of, Tva cy tvc)l / 41094 approximately feet/mile <br /> of T ,by performing the following work(description of work): <br /> (� vti it, ie -ul%r.la �S n M'Adle. Uwt,r <br /> A+c4 v <br /> Work will commence on or about o ad 1 t) for approximately O 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 /> a-- ,, I <br /> Sig re of Applic nt-Title ate <br /> E:P-S-SV.WKVMSTE NOACFIG{ENT PEWTAPPL'CKnON.DOC (0198) <br />