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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /2/22/0 OFFICE USE ONLY <br /> To: San Joaquin County JOB# rjb�� REF# <br /> Department of Public Works APN CR# <br /> _ EXP. DATE <br /> /!+e Sou.cc 6.vc yo Z„c. VALID jr 2� TO $—/S 2d(?_ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD 1� <br /> ?V`y /1c 60c".16 IQ le, Al TYPE �(lll�o�w� t;�J2�� �45�4uc4wv�l� <br /> ailing Address) FORMS <br /> q NOTES <br /> Gia S i e-A <br /> (City, State,Zip Code) <br /> (S3�) 9a6- �iSciS <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed/plans may be submitted) <br /> S, 4 h�Gc/).tl t'GUiG. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the wesf side of Sfa: sy ee.71 approximately 7v0 CreWmile so-f ti <br /> of A c,,QV // /,Z by performing the following work(description of work): <br /> S Cir W.�" It /�/S�iv✓/Yt_ c [.+G f� /M O/�/'70rMy G+Sy '.. Son a./��c/�C.LU1 �1' <br /> Work will commence on or about- 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 /> zof�-- — 5-1.1;r 5;:eK f.�f /z/z/�� <br /> Signature of Applicant-Title Date <br /> E:1PUB-SV.WKWASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (01,08) <br />