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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date �U ` -- 22 - <br />To: San Joaquin County <br />DepaeM of Public Works — <br />(Applicant Name) \L <br />�l'Jle 1'JDGvrs zai _ <br />(Mallin ddress) <br />(City, State, Zip Code) <br />LD I Z � Z bCo 53 _ <br />(Ara Code - Telephone Numbi�) <br />S–r h I l/ P&-r�t ", S�• c <br />(Emali Address) <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />730052 REF A <br />CR M <br />TO 4/1/2023 DRIVEWAYS: <br />Grange Ave. <br />AREA <br />TYPEaf7rr <br />FORMS <br />NOTES <br />btocKton WAD CC <br />SS/WVV <br />Special Conditions <br />Sketch (Detailed plans may be submitted) <br />Lam,,✓ � 2 <br />22 <br />Ll <br />The undeereby applies for permissan to exrate, construct and/or otherwise encroach on County Highly Right -of -Way on <br />the side of tI r il4l"4 approximately CL (fwYmile <br />of J `� I ri1,K r ' _ 1 �zt h•� by performing the following work (description of work): <br />-Tc ✓I J.{'_, ✓ 'twr\V'- . C/ .) d i � +[-v r'.,. O cl J <br />Work will commence on or after/ j� j� I t L for approximately days_ <br />I, the undersigned, certify that I am� respective property, or am qualified to represent the owner and agree to do the <br />work described above in acoo� with and regulations of San Joaquin County and subject to inspection and approval. <br />• - Date <br />Sk <br />-Fa.� .,..-., ...,..tea.. .� F•......,+,>w..�.es-^aaaut=ve <br />