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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date a-S-Z?i <br />To: San Joaquin County <br />Depa ant of Public Works <br />(Applicant Name) <br />22 \l <br />27t`JLe I�DGws Z"l <br />(Mallin ddress) <br />6,0 4 <br />(City, State, Zip Code) <br />Za`1 ZI2 1�k(o 53 <br />(Area code • Telephone Num r) <br />5—f h Pry P, <br />(Email Address) <br />JOB# <br />OFFICE USE ONLY <br />730052 REF# <br />APN <br />CR# <br />EXP.DATE <br />VALID <br />STREET <br />41 lulzuzz TO <br />Cotta Rd. <br />DRIVEWAYS: <br />AREA <br />TYPE <br />Lodi QUAD <br />Pole Repair <br />NW ' <br />FORMS <br />NOTES <br />SSfVW <br />Special Conditions <br />n <br />Sketch (Detailed plans may be submitted) �t <br />s" X <br />The undersned hereby applies for pP��mussion to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the side of L✓. C64-4- r(l approximately feet/mile /k -i <br />Of bn k L. i by performing the following work (description of work): <br />Work will commence on or after q -10 - 22 for approximately days. <br />I, the undersigned, certify that I am the respective property, or am qualified to represent the owner and agree to do the <br />work described above in accoroamZ with s and regulations of San Joaquin County and subject to inspection and approval. <br />Title . - <br />1r 1 <br />L{_S"Z2 <br />Date <br />