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APPLICATION FOR ENCROACHMENT PERMIT <br /> i <br /> PLEASE PRINT: /2019 Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APNCR# <br /> EXP.DATE .z rA. <br /> _...A,, VALID 2-/-Zol TO DRIVEWAYS: <br /> (Applicant Name) STREET 4U5T1N R04r0 * <br /> AREA 1VAA1r6-ca QUAD Sc <br /> $170 CLDCR GPF._EK � TYPEti <br /> (Mailing Address) FORMS Ss <br /> NOTES <br /> AC94MF_NT0,, CA 9 93 <br /> (City,State,Zip Code) <br /> 650-670- 0530 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PEW HAVEN F_LEM.EM-A PY <br /> AM 206100 OS- <br /> The <br /> S-The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of--Way on <br /> the <br /> th ) �1 id1W.� A pproximately IC200r feet/mild 50Of lTfH <br /> A�20�3 MetTLY �7� by Performing the following work(description of work): <br /> ILccn OF NEw NAPE TRF- BASE <br /> of A v?Tc.T'TY <br /> 04 1 - 'fU TK E 5C!,{pOL_ <br /> Work will commence on or about f. 20 for approximately 2 days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent ttre 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 /> Signature ofApplicant-Title $ I <br /> Date <br /> Eft64V.W01AMP gMAN*KrA7MWC WAq <br />