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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID /D .3 TO ;� DRIVEWAYS: <br /> (Applican Name) STREET ejjj <br /> AREA QUAD, ��-LC <br /> 31 (0TZ gc�r:�t c� �OA� TYPE ,2re�/ <br /> (Mailing Address) FORMS i <br /> NOTES <br /> Angio CoRW,4- GA. 9517,11Z <br /> (City, State,Zip Code) <br /> G-- 63-_1; - `/3110 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> `g?,, of G'i175 - 7 15 l -�� i�� ��"' �K ?wo GcTi9re�t/ D2a✓EI25 0� <br /> 20�.� GLosu,�E <br /> �,Povr�C �G✓G 1L*'�T/D�t/ moi , Scxr�aG T4s►oFi%�t�� c <br /> � �or-,,�y �'.�.�7���'�'.✓'�,,s'a�-,�' ,�ov ,�i3�n��✓,gvC� �Czo4� 418-3o?�f, <br /> 6 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the % side of 6� PORApos;�P �i approximately 1A';Io ee hile <br /> of Y3;i&je 1r by performing the following work(description of work): <br /> r <br /> or 6r, l e jPev,a.kc4 ,4 t,. 416 �a <br /> G, �NlsiCfl -�rn.Pi Mrd �.!'Ty� r 77J�1C'fpl.�. GZ {p <br /> ca 6ir V-F0c6f a o.,+v.."E" A'A S�IDC� i <br /> Work will commence on or about 3 tj 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 /> r,/, )Xk <br /> Signature of Applicant-Title deo yT Date <br /> 'CW"! — <br /> E.1PU&SVWNVAASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />