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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> 1 <br /> To: San Joaquin County ' JOB# _ REF <br /> Department of Public Works APN CR# <br /> EXP.DATE Y6"—204 <br /> VALID ( -243,- TO �C`a^�� DRIVEWAYS: <br /> (Applicant Name) STREET du <br /> AREA irrhz QUAD � <br /> 1 '>1+i1 x,ZE+1 r 4�4-v ,� .T i Li I TYPE , Y <br /> (Mailing Address) FORMS 2a� <br /> NOTE +� <br /> C ZLt r ra 14S` -I tAlc2�2te*� ' <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �5 r .A-777AGj-16"0 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the /(10Z 7-« side of . Sc..r-t,-2 k2 Q approximately 2o' f_.s r-- —feedwile <br /> of M vvr+7-A7;W ;1-w= /01"- 1 , by performing the following work(description of work): <br /> PLALC arI ZS " HOP E- 6 .azar,—ifAL- is—zt <br /> i 2.4 4 a V6 :2— ,'�.y_3 �*a..*-f e c_: .0 <br /> Work will commence on or about_ -Z -t ca for approximately / 4days. <br /> f,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owne 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 /> ig re of Applicant-Title Date <br /> :.'.PUB S/WN'J.1ASCEa-GS`.ENCROACH%li f:P E.Wtl`APPLICATROlN.00 <br />