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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date - J " aL(� OFFICE USE ONLY <br /> To: San Joaquin County JOB# � _ REF# <br /> Department of Public Works APN CR# <br /> -}-� EXP.DATE G-1,5 -201k <br /> � <br /> 1 VALID -j-ZU it TO G-/S-2b ll DRIVEWAYS: <br /> (Applicant Name) STREET <br /> oZ�UC� �_ � 16�►r ��_ AREA UAD <br /> Mile— <br /> TYPE e - I bcr <br /> (Mailing Address) FORMS <br /> ,S1QC,J��T -n LA - `7 � —11 U NOTES <br /> (City,State,Zip Code) <br /> 2Dq L-1 _� 1-I 9 _� G c- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> P 11 <br /> D61e_ <br /> D ,f 7_- Z 1D <br /> PJ�sc Spo ,4 T, (L <br /> The undersigned hereby applies r permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the z�u t (n side of (✓1ST m U �� approximately �OcD feet/ ile C—� L;J <br /> Of L�tJ�S T �A��2 by performing the following work escription of work): <br /> 4�/OS 7- ✓12 % S i tiL <br /> 7L Y <br /> Work will commence on or about_61,�' 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 /> i <br /> 112 <br /> Signature of Appli nt-Title V Date <br /> 7!,E-SrhlfMAS'r.RP5'ENCRCA,;AMEN-PERMITAPPI.CA:-,Ncoc ,:':del <br />