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1 i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date , ` OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73C°G 7 3 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE f"7 ,jam 2tlq 2- <br /> 4 — ej: �J'jLll'U�/� 'lam VALID O /,S gal Z DRIVEWAYS: <br /> (Applicant Name) STREET JACs� Q �iC JU `°\ACrn4t'n lz .. <br /> _ AREA `l�p� I A L,-.I- QUAD <br /> 7 <br /> LS An -\YTYPE `� �I�v(c.c S; . ►•fit.. <br /> (Mailing Address) FORMS S UA) <br /> ET— <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the F-/��'T sideof 1NbR�i�i�ry RD approximately feet/ ile NOP,734 <br /> of U-5 -Tu p:&�c YL �l� by performing the following work description of work): <br /> X LO <br /> \IACkL-7 n\..? V- -qA )D Lk. -T -F12-Et-,,L-k-j iKef-"i <br /> l y rr `PTS—77 Cc�r� c �T F) OM Li <br /> CLC LA '"rG <br /> I.� <br /> zS-\,ja7 -(-,_TGC )Ja�-Lj 1 LA)C'K. c-41'--b,Ci <br /> Work will commence on or about 7- /�T for approximately D 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 /> Sign ure o rMiTA <br /> ca t- Date <br /> E:1PUBSV WK1MA R.PSIENCROA ENTIC (01108) <br />