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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 'Z- 2 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> L ptDEPj-P7-beS it EXP.DATE S l IZ <br /> n�3�c'►1 uti �`�wb�� VALID 5 i4 TO <br /> (Applicant Name) 5 ►�- DRIVEWAYS: <br /> STREET <br /> F00 NT y * <br /> PO • , S3-7 AREA ►ti� QUAD <br /> TYPE <br /> (Mailing Address) FORMS -� <br /> L <br /> NOTES <br /> rvD�-►.► C,t a- S�s- b AA 20 z - F� <br /> (City, State,Zip Code) %30 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S � w <br /> � <br /> if l L <br /> P«"'}te5 t M�,le' YL7'N /T TV, <br /> L <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Nm2-0- side of F/U Ar,— S 7- <br /> of approximately feet/mile <br /> Cti, <br /> by performing the following work(description of work):S f� Qe�we /M 4/�Icy l S r o n� Tit3 r ,4�y0 <br /> b U cti r9 i� 2,90 r 7"7ir T. �/L9 y 3 4 I D c 4►� <br /> Work will commence on or about / 20/:�- for approximately b u,5' C 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 /> Signature of Appli nt-Title Date <br /> EAPU8-SV WKWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC )OI/D8) <br />