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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �J` �} - 1z OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> VlZbll� - SAir� .1 EXP.DATE G ! /Z <br /> VALID �� (� f� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> * <br /> �^ AREA nt 3jlcAi QUAD /{[� <br /> 3D LU. C ��� �T TYPE �.( IN <br /> Ohl <br /> (Mailing Address) FORMS SS/uarv, ,�29 <br /> fU Tt✓C,a, , �� ��5�.�� NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ATT KcReLb <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw Right-of-Way on <br /> of <br /> the W E5T side of F7RoNT -IT approximately 25 fee ile 1\4 02rW Y Z CT�� L 1 by performing the following work( escription of work): <br /> t�r�ct< �ao� orv� 4- CCU DL) IT AT 3(," DEPTH FR�►v\ R y �� IZfG HT <br /> ©r U \ TO A, ��I N T S co G S �� <br /> ` TL) T-4 C1 PST l-F R N D U)ET , 1UJ {A <br /> T4+� CO�vOL) t [- WILL SL )LEP TD &P-,LIC OF CoDIUTY K 16 H7 <br /> WA`s L7 POLI- PT CELL SITE, -rF--AP+FIC , tEC) SpLkLF- WILL <br /> BL PLptC�� PtPPRb�lNIAT L4' SD' E—P,0fr\ I-lLvY 2� 12tC�k�T D� (t)F��.. <br /> Work will commence on or about J�IP PSI _ I D ZC�l 2 for approximately 3 D <br /> 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 ivies and regulations of San Joaquin County and subject to inspection and approval. <br /> C _ <br /> -77 <br /> gnature of Applicant-Tine � — � <br /> Date <br /> EIPLBSV.W1MASTEFLpse4CRQACHMMpERWrApp,jCATIWWC pinj <br />