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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Lf/`1� OFFICE USE ONLY <br /> To: San Joaquin County JOB# "106W REF# <br /> Department of Public Works APN j CR# <br /> _ , EXP.DATE Z <br /> /AP���c'4:c;�� _)oil;7-S!'q ;�c- VALID /z/r ry DRIVEWAYS: <br /> (Applicant Name) STREET �� <br /> AREA QUAD <br /> TYPE ll�Gl� <br /> (Mailing Address) FORMS lt/hJ <br /> nn .{ NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permiss on to excavate,construct and/or otherwise encroach op County Highway Right-of-Way on <br /> the ncc- 1 h crfti side of �. K�f��-M4'? ZA approximately 1000 (R/mile WcS -1 <br /> of C,I t c, ue . ,by performing the fol owing work(description of work): <br /> GOA I �Ce'f 2ilu:n L/1 c, t li I h� �n , X77 f• c.{ 4��Yt c:-�I1)),n <br /> Work will commence on or about --q-11Z11-Z- for approximately I days. <br /> I,the undersigned,certif m the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described abov n accor anc with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signatur n - Date <br /> E:,PUB-SV.VM MASTER.PSIENCROACHAIEWPERAIITAPPLICATION-DDC(01W) <br />