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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />AN D`7 S;� <br />(Applicant Name) <br />(Mailing Address) <br />x C 0 �1> -�-o .o -fit cls> <br />(City, State, Zip Code) <br />x �? <br />?2 L4 r5 -2,6,q <br />(Area Code - Telephone Number) <br />k &A . m a U L -L -C, C�\ » r PV11 <br />(EmailWddress) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />110005 REF # <br />CR # <br />2/1/2024 TO 4/15/2024 <br />Mello Ave. <br />DRIVEWAYS: <br />AREA <br />TYPE <br />Ripon QUAD <br />Bore <br />FORMS <br />NOTES <br />SSA/\/W, R-29 <br />Special Conditions <br />S e e a..A Cde.0 5 S l" c; <br />W ATom. P_ Frtz' fF-4 CA X i o 3 <br />SoePL'f <br />M <br />1IQC-, <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the Ni S side of Nt e t.1_0 P—v AZapproximately 0-4 Q feet/ o mile W <br />of C,e' g j j. P___4 pct cA , by performing the following work (description of work): <br />J iiiA (Z pv" C-L-A_ss (40PIPS U�--)rEp_ <br />M c L_ L X> 2 A� 1Z i i a rJ , CA <br />Work will commence on or after X :d for approximately z 2. ---:? 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 A60bAtIlTitle Dat <br />