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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date � 1- 1 f - t j <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # 706179-3 REF # <br /> Department of Public Works APN CR # <br /> ?�( <br /> „r C <br /> EXP. DATE Z 15 6 R CLL D(3P,, f VALID (l Z )0 TO 1` -D DRIVEWAYS: <br /> (Applicant Name) STREET +:9a�2D1� # <br /> AREA"GA cy <br /> L I r � � 14 C '�,I LIZ (ZD TYPE `�'4 c 'QUAzcz� <br /> (Mailing Address) FORMS w _�Zg <br /> -2', NOTE <br /> 013 CA (� 521 D <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the }. <br /> F� 1 ELQ 11 side of <br /> of CCLC _ approximately l�1� rJ feet/mile <br /> - by performing the <br /> following work (description of work) : 4", ;' € U '3� <br /> 7"c1 L,I_i� { i 111' �' L l 11 v- CSL 1i 1 i' lel vt L)'Q.C <br /> Work will commence on or about - 'i <br /> rr� for approximately <br /> , - ,Says <br /> e undersigned certify that Z am the owner of <br /> the respective property, or 3m <br /> 1 alit'ed to represent the owner anal agree `o do the work descrihed above in <br /> accordance with the riles, regulations Of SanPaquin _(7 <br /> csr.�y and st:b4Act <br /> ._sped i cn ard_,7p=.al. <br /> Signature c, Applicant - Title - <br /> Date <br />