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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date - Ot - I 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB # �1�✓ REF ## <br /> Department of Public Works APN CR' # <br /> � -�- �� _ EXP. DATE <br /> SLS`_ VALID S I T 9i- DRIVEWAYS: <br /> (Applicant Name) STREET LEy Lith` <br /> }3l?� 1 1Gi 1 1 f1(1i�C- R h AREA ✓ QUAD A45 <br /> TYPE,-&W $94WZ /50-CW7- <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> y-1 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> t '�T ► �o i� `1 Cl 31 to`t r <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the S+aOT?i side -of <br /> �';qAL-el t_-t4 approximately & feet/fie, LfAc l- <br /> of 'FCPPI Ar!ro L_).4 _ , SI'bCj I"Ot� (WkMft p , by performing the <br /> following wcrk (description of work) : RLACC 1 SAJ1Aq ZL VAt1lT-" wlt-H YYtA HOLZ <br /> Cz' a(L . z�,�n a c�P(" NT-,-T- 4-4" CoNo�)tr !NY4N i-\A" C,AOQ �r WA-IL" r'EEt,5 -"Ae <br /> CLA1, s 1 tE. A-T' 10(o! ' FO P P C A ik LA*LE IVF- 'MiiAI'S) 4`x Y`x y i fk-LOQ <br /> G,zoo&lo An.D iS TO 'S�rAn1O A-VA)Cr.- Wc1GtAT` <br /> Work will commence on or about rd - 11 - fit for approximately <br /> 30 days. <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 /> i <br /> Signature of Applicant - Title Date <br /> MA.S:ER,PS\PERSCEML i6/00) <br />