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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date "t - — Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# ` REF# <br /> Department of Public Works APN CR# <br /> \ e SEXP.DATE 5 i 17, <br /> �-�•) r O V'�S\ VALID 1Z T S ) )Z DRIVEWAYS.- <br /> (Applicant Name) STREET 1125-;p v l- <br /> � :� AREA � d��y QUAD <br /> 0 S� S � SAN SoS� TYPE ertc� <br /> (Mailing Address) FORMS 1;/�,, <br /> a� JOSCNOTES ''S 9S ISQ <br /> (Cit , State,Zip Code) <br /> zog - 9y3 - l�a � Z <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> mpRS� <br /> �3 1p <br /> mARS �. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Sau't1N side of So 3l, I'Y)t>ps(�_ St approximately. I QQ feet/mile�u� <br /> of nti��ou v av 2 by performing the following work(description of work): <br /> Work will commence on or about y— I I — 1 for approximately 10 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 /> e ry,pv c - C? _ / Z <br /> �-- Signature--of Applicant-Title Date <br /> E.MB-SV WKVAASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (01108) <br />