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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date // Jia OFFICE USE ONLY <br /> To: San Joaquin County JOB# P\,\j P It000 S REF# <br /> Department of Public Works APP-) CR# <br /> EXP.DATE 201 7 <br /> [JU l ei�iS �l l4'i rcn rney�f�l j n e_ • VALID -21-54 2-TO S 1 -ley 1 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> C�. p CSX SSS qAREA < K�bk QUAD NS <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> 0-1e'— CA <br /> (City, State,Zip Code) <br /> 9c(19. 0333 <br /> (Area Code•Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 5f-C- CL`i&C-kEA <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the esI- side of i�Le.:-}-p Ai _approximately. / 8D -0mile noa <br /> of -r-he ccn+- I i n e✓ of- wcc-I-eLLL2 by performing the following work(description of work): <br /> w ..� t. tl M -1 cin !✓11�?-l�I�, (See- ctte�Checl <br /> {� r nn a-Efer fPnenv'jnn moot.�i+r II f ��5IJ <br /> J <br /> Work will commence on or about r -j �o I for approximately 14I hrs�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 /> Signa ure of Applicant•Title Date <br /> E:PUB-SV.WNIMASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />