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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date G71/i 1 i 1 - OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7,36C62 REF# <br /> Department of Public Works APN I CR# <br /> EXP.DATE <br /> VALID 7 b TO 12 DRIVEWAYS: <br /> (Applicant Name) STREET ' <br /> AREA Loa I QUAD NW ' <br /> i I �� ! ! l i)H TYPE 'per u. P Iai.ES, AE? OT- <br /> ( <br /> (Mailing Address) FORMS1,�luJ, j2 Z4 <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> K VD '�L\ T -�f\L e1) 1zrE�AjI �1��5 . <br /> 2- <br /> The <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 06,,Tf+ -r SouTjisideof /�R�1Si�o�1 b X17• approximately i' 9/ feettmile <br /> of V/o KK i-0 i n��a it 13 o,IZ e- A(Z-w"S'qe)N U ,by performing the following work(description of work): <br /> gQeO U NI)FiZ AKM 3[Ec,1lC, 10. S' PEEP, CY-6S1,11'u v SQU x-1.1 Ta A)69L/- <br /> ,IJ21�nJ( H EAS-7 l71 el si OnJ C)317 OF P1LJ A) i 76 ENI-E-K r'q-11�1� <br /> i <br /> 20 Tr1L�Nt�kl iO Bi �, t/ A2a4. J7�ro�J C� <br /> Work will commence on or about_ --7 6 ► z for approximately -3 y 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 /> �- <br /> Signature of Applicant-Title / Diate <br /> E.PUBSV.WKIMTER.PMCROACHMEMPERMRMPUCATONAOC(011M <br /> �S � 2C� ,C - / <br />