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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date i d OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000s- REF# <br /> Department of Public Works APN CR# <br /> �j (AMADO-a <br /> /1 EXP.DATE ti l3�E'Q�'p F�EI tJ K N fir' (�'CY) VALID p 23 -5 TO 3 DRIVEWAYS: <br /> (Applicant Name) STREET Lr 0C__Q_T ! lzo. <br /> AREA QUAD A4!� — <br /> ��y Cov2T STQt� T TYPE "i1zAfIF c- CONT PloL 1136,J C _S <br /> (Mailing Address) FORMSLN .� <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SLS A rFA C"m E&v'r <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the SOL, rxA side of>;�5� .T' laC3�R�'Y approximately (400 -�eefeet/mile E►"`JT <br /> of -S-t-t�TC P_OL TV-_ by performing the following work(description of work): <br /> -�� P�`cTP�c N>�n ��s��t per►o�i <br /> Work will commence on or about C`ZcTy See_ a3, I for approximately 'S 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 /> 5P_0N vfL L I'll I— I D 1 -,;=-) I I <br /> S ture Appl' a -Title CrJ&%tNf bate <br /> Pc M t��'-x.72 Cca��T`•C <br /> EIICENTRALSERVICESICLERICALLWBSV.WHV.WSTERPSIENCROACIi"EyTPi-WAITAPPLICAT10N.DOC{09113) <br />