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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date .9-- OFFICE USE ONLY <br /> To: San Joaquin County JOB# IPjX)P Zger,S2IpREF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Z1,1S,20141 <br /> VALID 1,Z-.<-2G3 TO L[-IS-201y DRIVEWAYS: <br /> (Applicant Name) STREET Loway` Sac yr,4&CA,* <br /> AREA UAD <br /> 6)z-1 13V a A 1;R'.- Cwai -P TYPE T r L k <br /> (Mailing Address) FORMSq� <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> o'� F-t-� fir:)t 1 ��jT L <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way-on <br /> the side of U W6�dL iD approximately feet/mile <br /> V-15 ,by performing the following work(description of work): <br /> Ct1 t t ) �A LL- p iw'A <br /> L�IKE S (YzA16D Nam <br /> Work will commence on or about i 7 f for approximately 10 days. <br /> I,the undersign d,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work desc` ed o in acc rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 12'711 Z <br /> gnat of Ap rcant-Title Date <br /> ESPUBSV.MEASTEUW.F.NCROAO*.'NiPEREWAPPUCAMNDW UttJe) <br />