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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I / -zo j( OFFICE USE ONLY <br /> To: San Joaquin County JOB# //mss REF# <br /> Department of Public Works APN CR# <br /> 1�u�5DEXP.DATE 9 it ish�l C (o VALID G0 G N DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA <br /> (p C VL a Y ke Y TYPE QUAD _ <br /> (Mailing Address) FORMS <br /> S 10 C- NOTES <br /> opt , C S Za 5 <br /> (City,State,Zip Code) <br /> i <br /> �20� � <br /> (Area Code•Telephone Number) <br /> KA4e&rj ARA t — 42- <br /> Sketch(Detailed plans may be submitted) <br /> a;lt�G c�e oL 5 ��euv .`��o�osec� o�. " v LAS- C vo v2 <br /> No 6,'W"Vl 51 5 W1 �1 6r- <br /> The <br /> -The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on j <br /> the side of approximately feet/mile <br /> Of by performing the following work(description of work): <br /> 1 Ye q � Q(Ae- i2 Cues Z �d v� g C� `Cln(Ar vne`l' <br /> :Dd OO rWl 9 i u ki LIC611Y �(2UrulYP� �cn IkY YYI� <br /> ¢CLSSa�r Yvla��t zn vt uvbYtc ova 24c1 S a is Y2 S d v vn er.k lnrar k Wi 11 <br /> kyl A6- Y2 aViw \dPi✓ 1v1alvt Govt ne.+.W G1A/c'xt1QY� <br /> tl <br /> Gly�tvl v� S <br /> Work will commencd on or about_ v�� :a ,2-61V for approximately Yee, days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the wner and agree to do the �L / <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 /> FL UMV.VlKKASTERPSFINCROACKMEMT PERMIT APPLICATION.DoC pia) j <br />