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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 ' Q OFFICE USE ONLY <br /> To: San Joaquin County JOB# a446;2_-_s' REF# <br /> Department of Public Works APN CR# <br /> !+ � EXP. DATE <br /> VALID 411 <br /> / o _ TO DRIVEWAYS: <br /> y(Applicant Name) STREET c��,y�-xe�2 c AEC <br /> AREA SCJ F�N�iIZ fAiZ1C. .L�C� , 550e,4"!✓ QUAD <br /> TYPE �tt0 <br /> D <br /> (Mailing Address) FORMS <br /> NOTES <br /> �.s A 937''=0 <br /> 'City, State,Zipe Code) <br /> C55ti) 7^57,4kP _KAgK PXc*r6s <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Y4-T-T� _,k-e C�,- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 1AdWT%t* side of_F_T4 .1,T_ 9� ?.O <br /> qD _approximately ''2� mile W <br /> Of VV�T 116M6 by performing the following work(description of work): <br /> STD jjse>�+,CgN E1slc 1r3PUtE�1'r' a� �x�STs�k�, PCIS <br /> Work will commence on or about_ ,`-! 10 for approximately C� 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 /> AlVel� 04�__ - <br /> 14 ,O'9`24-- 201 G <br /> Signature of Applicant-Title Date <br /> E1PU&SV WKWASTER PSIENCROACHMENT PERMIT APPLICATION DCC (01108) <br />