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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> CNF-Is WrEY &OA<A60 VALID 7 T S JL DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 4520 0A0TAS . 4-1V &_7 TYPE <br /> (Mailing Address) FORMS W <br /> NOTES <br /> STack'Tok>, CA 45'R0& <br /> (City,State,Zip Code) dL —1,6) 'W-5 <br /> e6so) 3z3-h/S5 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) SEE A—TrA C HSb <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the,�I�.side of A R�u �� approximately—S S H 1 Lb feet/mi16(&-fRE _ <br /> Of_�t� 111 19'n- . Skx-kTOLA ,by performing the following work(description of work): <br /> i!&JAi-j— d %TO,!�n ?0L-r=S A iZ.CN 7Z. aoxm- m2p, ' [IarTIJ <br /> of A&<eq LZ TL> Soc fro ac Ai['.:A:► K� -- iNST9.1�L-- <br /> C.oA.')-A'-c4 rr- f-o Q CAry to- or WgE - <br /> Work will commence on or about_ - — ! for approximately 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 riles and regulations of San Joaquin County and subject to inspection and approval. <br /> /L4Y <br /> nature of Applicant-Tine Date <br /> EFU"V POW ANWAMKOW OL" <br />