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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date N OV 5 0 D OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Waits APN _ CR# <br /> � (( � ` EXP.DATE <br /> W 1s—Zal 3 <br /> 2'G Cons7YJt.;cy\ VALID I-ZG-�tl TO 3.16-2c>4 DRIVEWAYS: <br /> (Applicant Name) STREET %&VAI MU 11 It1b. _ <br /> QUAD <br /> Sso C->�Q �t LC ed TYPE <br /> (Maibng Address) FORMS g (� <br /> NOTES <br /> (City,State,Zip Code) <br /> 60(0 - 2 er'oo <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) L { 1 <br /> C-_ <br /> - ��.t-t`���. P�(a <br /> ycp�'C <br /> C�c <br /> G _.... ��,� �Carmetr\�o Q-a-• �C,2�pEa.-��• -' �a��-�fid. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of_ approximately feet/mile <br /> Of ^_ by performing the following work(description of work): <br /> QA-TA Sivel-1p t i U&P-6aJ &Udlc 9&0e%,. ovti C: <br /> Work will commence on or about A for approximately Wqe_y_;nGJ days. <br /> I,the undersignedaefkfy that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work descri above A accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature®6f Applicant-Title Date <br /> ETL1DW.YeN.iWMRP9&CRaV"JE T POW APPLICATMDOC FLCBI .. <br />