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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date --Z"!2 OFFICE USE ONLY <br /> To: San Joaquin County JOB# lr ��a-S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE — / <br /> hGH jri L 6 AS+-e�c-'�tC VALID � TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD Ate' <br /> Rt\i 'TL F'421L-f>LA Ce C-ArSr TYPE o � /���?�✓�ES <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Cade-Telephone Number) <br /> Sketch(Detailed plans may be submitted) 1. ?J& ►v� r 516-A Qa <br /> :E�c <br /> CQ N S / v <br /> M UJ AA, 11S'� ' of cue <br /> 1 l nRau cA4 EXISTS NC�j tr +W� <br /> COb7m rr F/D LR�s GS • ov <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wayon <br /> approximately I m"f feet/mile <br /> the Svc side of C`s c � r.� pp Y ' --— <br /> of P. oc.K.. *�� 'co N5`-MuC-7 0o Cc�c;�T�>wvt`� su✓r/t ,by performing the following work(description of work):, <br /> f t/ S P"rv�'i`�t • ,oci £7- G�7�5 .,S w rl &AA cot• j-Au e - d'l <br /> sfrQ4+t-�#Zu n C2ar• eS c Q�, Mr -Q.0- <br /> 16 0-WI <br /> - <br /> Work will commence on or about ?_-Z7-t 2 for approximately IY6,1S 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:;S* natureof <br /> d above in acc nce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> pp scant-Title Date <br />