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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: n <br /> Date 7 ZS OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> \1 EXP.DATE <br /> VALID q i 0 <br /> (Applicant Name) STREET Z DRIVEWAYS: <br /> r � AREA <br /> _ QUAD - _ <br /> Ott. TYPE Nl�tll\! <br /> (Mailing Address) FORMS Z <br /> L� QS'ga� NOTES <br /> (City,State,Zip Code)` <br /> 60- iS_gs <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 3� <br /> The undersigned hereby applies for permissio to excavat ,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the �� side of o �,o T1 V--n& <br /> of 4" HP FL 1MIK;h --G0-5 approximately (�,��n feet/milebmt <br /> ( H P PL C��s�ryby perform'ng the f (lowing wok(description of wArk): <br /> o� (,�es�� � � <br /> iS�Z 1 4 S¢-v Uig 3� 'i U,Iif\ <br /> Work will commence on or about_ Sit. Q,,,� a.�\ for approximately 1:570 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 accordan with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i J3 C 8 !1 <br /> Signature of Applicant-Tie 1 ate <br /> E'TUB-SV.WKIMASTER PSIENCROACNMENT PERMIT APPLICATIONDOC (01108) • I 14 1Ar I I O7 <br /> o' <br />