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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# f Q REF# <br /> Department of Public Works APN CR# <br /> EXP.D/�/1GA�T (AN9QRV PECK VALID ATE T /2 Z DRIVEWAYS: <br /> (Applicant Name) STREET V14/—y'59,e711 r> ' <br /> AREA QUAD "*: ' <br /> 170 ELDEK CREE}- RD , TYPE -e nc i4oL.E, <br /> C, ! (Mailing Address) FORMS 1?yjwAU, e 2� <br /> �1Y �E1�Tfl CA /Q 5S2LI NOTES <br /> (City,State,Zip Code) <br /> 650-6-7p-053 0 <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 Highway Rightof-Way on <br /> the - side of WXLAAAFZT RD. approximately �i mild�J <br /> of dWY t VKTE UX) RPD,1 ,by performing the following work(description of work): <br /> EES M2 Ro2E (?A-TW N A. tJr� / PdLF AND TH I- <br /> M WE 0r- 3555 V111 l 1/ A� ED, <br /> Work will commence on or about j for approximately 1-2 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 /> ure of Applicant-Titte/ Dafe <br /> EIPUB *VWSMRP51ENCAOl1p1►mRP8WAPR1C rMWC Pt" <br />