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Y <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date — Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# bpo-5— REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> UQLLey CO+vSf VALID s-Icl-Zr3/y TO -1-7�1�_ DRIVEWAYS: <br /> (Applicai t Name) Lic, F7 y 9c,g STREET <br /> AREA <br /> d �otC 5 6� C� S cao-, -� 4S-Q TYPE <br /> _tft <br /> QUAD W <br /> (Mailing Address) FORMS /w w IE29 <br /> p��--J / s; NOTES <br /> I <br /> (City,State,Zip Code) <br /> Zai - (big 3--65 1 2 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) a or iz <br /> area o. rqYnto" neap f <br /> w_. <br /> 1 o p <br /> �E � I SOr 4_3 <br /> do <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Er&� side of rQ approximately (Z,S ') ( ISO' ) feeftile 6�c �,•1���, <br /> k y al.-tut, s-� by performing the following work(description of work): <br /> l,Joec�bR�c�Go Sewe2 M%st. T'(1� Q �2PC»�tR ON <br /> k �ezdk�►� S e .,��. m�� ►.� <br /> Work will commence on or about Ll I�— t ? for approximately_ S 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 roles and regulations of San Joaquin County and subject to inspection and approval. <br /> Signa ure of Applicant-TitleSt�k�.(3► Date <br /> E.IPU&SV WKIMASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (01118) <br />