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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date `s- - ;� > zL 't _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 19M57 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ��. 13 <br /> tl'OVt�� `..�/RC1 %v VALID 7-114113 TO 3 /3 DRIVEWAYS: <br /> (Applicant Name) STREET t}wY <br /> AREA p pzy" QUAD <br /> TYPE 7e& 3e'w <br /> (Mailing Address) FORMS n; -24 <br /> NOTES <br /> LA <br /> (City,State,Zip Code) <br /> 1`'1 L C'1 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) S-rt C. U(2_ tz60 t)U _3 C <br /> LN EL_ _ I'rel-V( C LL. !i E <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Nc k-rl-t g F6'�- side of approximately `x-00` feet*ft 500TA�EA.3T <br /> of AU 5 t wi Kk P6 K3 ,by performing the following work(description of work): <br /> Su GZ1 E C) D e\_01, �K0 F_M C) OF eYu Slf_!C B U P C (-z e -7�, cc)m SJ u 1 T <br /> P-LILFILL kj,) 1 i H NJ q--. TV,EK)LH _:S Ln <br /> Work will commence on or about 14 ,2.D t for approximately 3CD 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 /> t <br /> Signature of Applicant-Title Date <br /> EiPUB&SV.WKN*TER.PSOCROACH ENTPERMITAPPLICATION.DOC tDINq <br />