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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I Z2— t f2_Q OFFICE USE ONLY <br /> To: San Joaquin County JOB# /fQT5�' REF# <br /> Department of Public Works APN CR# <br /> K �`� EXP.DATE l <br /> �nc. a'«^� VALID 11 TO / 1) DRIVEWAYS: <br /> (Applicant Name) STREET ` HAzr.Lr, __AJ6' <br /> AREA -w6ejk`rotJ QUAD 1AZ> <br /> 2001 t4rc h Int r?("+ SVLt1V_(Qo TYPE I Fvc 9 J=' <br /> (Mailing Address) FORMS Fe, <br /> A��2-0�!7 NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) ., <br /> $-D ►.t,� r <br /> C <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the No r--I�side of w. tk za-/fc,r\ Ave-- approximately 2-0 0 4-e.�_t feetlmile t,J1Q f <br /> of .0-0ce , by performing the following work(description of work): <br /> It24`r 1 r� t c(( `�'`r1J YG'f�t, � t't�G► 6�'t-�-�4 <br /> Work will commence on or about 179 <br /> / 76211 for approximately _ days. <br /> I,the undersigned,ce ' that I am the yawner of the respective p d �l�l ( <br /> g � .pec p petty,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 /> Signature of Applicant-Title Date <br /> E:WLI&W.MWASTERPSOICROA"ENTPERAIITAPPUCATION.DOC (0106) <br />