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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ^> 1 1 <br /> �f OFFICE USE ONLY <br /> To: San Joaquin County JOB # f 30Cs1J_j <br /> Department of Public Works REF # <br /> APN CR # <br /> - t } v_. EXP. DAT <br /> (Applicant Name) VALID TO l/ DRIVEWAYS: <br /> STREET 5 LES <br /> z:�c _ . C•1 1 i l i k 1' AREA QUAD _ <br /> TYPE M-646 +� 13GR.E. —'– <br /> (Mailing Address) FORMS �/ / ,�Z ------ <br /> i L C-kc i L?LA CCFi 4, 4-k 1 NOTE ` <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 excavates construct and/or <br /> IASH C_r.4 <br /> otherwise encroach on County Highway Right-of-Way on the Li ►l-4 <br /> C <br /> —`i--- y - - side of <br /> Of approximately feet/+&i-}.e <br /> 13 C. ib�1 C iilClt ©l <br /> following work (description of work F by performing the <br /> ) : iY1 r11H Litc'Z. ►It .w1('11 •411113 PLALC- <br /> PLACE:. t- 3'n S' �P�.-�cx. ae ^�..E <br /> tk) PLAN 2- ! '1y" Sr NiE-yzf cT �l� c,ZK tS D 121. <br /> Work will commence on or about <br /> ;o days. for approximately <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> r. <br /> Signature of Applicant - Title <br /> Date <br /> MASTER.PS\PEESCFML (6100) <br />