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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 'i- S - ZZ, <br />To: San Joaquin County <br />De"ant of Public Works <br />(Applicant Name) \\ <br />3l'�le frJDpot (a7 <br />(Mailing -Address) <br />(City, State, Zip Code) <br />Zo`1 Z -4Z- S;Ca 5-� <br />(Area Code • Telephone NumAr) <br />Pry?, <br />(Email Address) <br />JOB# <br />730052 REF# <br />AN <br />_ <br />CR# _ <br />EXP. DATE <br />VALID <br />4/10/2022 TO <br />STREET <br />ottC to Rd. <br />AREA <br />Lodi OuAD NW <br />TYPE <br />PoleRepair <br />FORMS <br />SSMW <br />NOTES <br />Special Conditions <br />Sketch (Detailed plans may be submitted) f� <br />u <br />b <br />V) . C�4�, <br />c� <br />I 3WA <br />,$� X C - <br />DRIVEWAYS: <br />The undersned hereby applies for ppggrmission to expvate, construct and/or otherwise encroach on County Highway Right -0f --Way on <br />the side of l✓. Ca+ til _approximately- ism feeUmile k.) <br />of L�� ab 1�✓a k L. by performing the followng 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 thgawn mspective property, cram qualified to represent the owner and agree to do the <br />work described above in acco0arCe v s and regulations of San Joaquin County and subject to inspection and approval. <br />- Date <br />