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Ps-i z Z5-cS- <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date [y - - I OFFICE USE ONLY <br /> To: San Joaquin County JOB# I/pDDS REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 2 / ;?- <br /> L <br /> L i n> ej —�tit7'S � �+atn CxoAm&Lct VALID 2 i /2 TO 12-411JI DRIVEWAYS: <br /> (Applicant Name) STREET ,moo vT— t2 f <br /> Vsc S,-mar_ AREA 11iy,09.,V QUAD <br /> TYPE TEn�O ,Qo�4� GGoSu�E <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> X <br /> Ile I <br /> S CCTI o r <br /> J <br /> v <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of L4Ne7, dvr\— 5- approximately feet/mile <br /> of 1 , by performing the following work(description of work): <br /> tt � 'Si✓2 <br /> f a--,, OA 5' 11 f1 vin �' !' v� r t Yo 4 , ✓'A�/ CAVz:DNz <br /> L*r-r v 17 t� C c w, y1n lr�v r i y <br /> Work will commence on or about 12- for approximately i u=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 /> 14-67-7,11 if r7rc <br /> Signature of Applicant-Title / <br /> Date <br /> E:IPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />