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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date `'t' 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 30D&Z—/p REF# <br /> Department of Public Works APN CR# <br /> C ® M D EXP.DATE / <br /> P(--4+ VALID // 0 / // DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ® �T_L I w AREA 5" �j�/QUAD <br /> TYPE ,P� G�@r✓12r� <br /> (Mailing Address) FORMS W <br /> NOTES <br /> q ��C) <br /> (City,State,Zip Code) <br /> "Ll- It-'Ll Z <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the SouTri sideof C0PaCR6PAL1 S 12..0ftp approximately 360 feet/mile UA <br /> of Al-M N G' Rit,fID STa c-K''0 by performing the following work(description of work): <br /> t . ,��,�►��rr� o� 'C'I�,r3I5+� s S� Iry oc c- rlqt, <br /> I-A13 "EI-> 0M PaLV <br /> Work will commence on or about for approximately 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 /> JF®Tt '� G�-t � !to l 7.010 <br /> Signature bf Applicant-Title Date <br /> EVFUBSV ISrA!"SiERP5E:00R0,cµ!g;R PER!4T FF'?UCAi10'lOG: �v195) <br />