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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f'1 2,a c t o OFFICE USE ONLY <br /> To: San Joaquin County JOB# / -5" REF# _ <br /> Department of Public Works APN CR# <br /> Q EXP.DATE x' —11 G - <br /> tcLVtJ.L ��RN14eyt m�lOtewi 1n _ VALIDl TO 5-',' DRIVEWAYS: <br /> (Applicant Name) STREET ,� �— <br /> AREA �.SG.4eWw° QUAD 11� ` <br /> TYPE �`t raSPi�r <br /> (Mailing Address) FORMS -- — ---? <br /> NOTES <br /> Owlet e C& q S3(.i <br /> (City,State,Zip Code) <br /> 9) srl-351-7 &x .zy <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> I L-Vkx� V\-0-5 co fin,.P Lz'J� VL'o 1 vs Q,,.,,,k c4se"'e' , <br /> C\ c L'-e54-)i 5 C", G <br /> i <br /> i <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 =T�Si� We. ide of €. approximately 6 r _feet/mile_-_ <br /> of 4�—M- � `'^ —ice=- V t w -i�,., �1r� _�s�,n�t c wi,�., by performing the foll wing work description of work): <br /> _r <br /> Work will commence on or about—_ 'Nov I 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 /> l i tt <br /> '-01 D <br /> Signature of Applican -Title Dante <br /> F%PiJB-SV.WKMSTERPSIENCROAC:.HPAr.N'P�RMIF P-LICA11UN.000 IMME) <br />