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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To <br />- !D- zD <br />San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />`7 q <br />(Mailing Address) <br />F� I?f IMC n A ,CSA . qj <br />(City, State, Zip Code) <br />�D�- r3B�- X321 <br />(Area Code - Telephone Number) <br />A 4(k OW+ ICU com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />& <br />�Gf�k'� 7 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of -Way on <br />the UaTN sidesof ESi',�lor►-�i�"t.i.,•� RD approximately 1 Ub0 ee ile <br />of �►ti�s Yz 5 ����-�) L Iw.�-( flu e KD i T by performing the following work (description of work): <br />2 <br />Work will commence on or after <br />2 <br />for approximately 5 - ✓� u2s c: 3 �� y 5 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 />Signature of Appl <br />- Title <br />Y:IFCRMS & TEMPLATESIENCRCACHMENT PERMIT APPLICATICN.doc (OSIOB) <br />Date <br />OFFICE USE ONLY <br />JOB # <br />&W5 <br />REF # <br />APN <br />CR # <br />EXP. DATE <br />2 q <br />Zo <br />VALID <br />2v <br />TO Z q 20 DRIVEWAYS: <br />STREET <br />E toscA n/- <br />QClGvT14 ,P.�. <br />AREA <br />)QjZoN�adr7jn/ <br />QUAD NE <br />TYPE <br />?,OAAQe CeAAIMOC <br />ZVVIC46 <br />FORMS <br />NOTES <br />��y <br />�2nl5 <br />rM <br />?�Zo <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of -Way on <br />the UaTN sidesof ESi',�lor►-�i�"t.i.,•� RD approximately 1 Ub0 ee ile <br />of �►ti�s Yz 5 ����-�) L Iw.�-( flu e KD i T by performing the following work (description of work): <br />2 <br />Work will commence on or after <br />2 <br />for approximately 5 - ✓� u2s c: 3 �� y 5 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 />Signature of Appl <br />- Title <br />Y:IFCRMS & TEMPLATESIENCRCACHMENT PERMIT APPLICATICN.doc (OSIOB) <br />Date <br />