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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ���. r✓� <br /> Date /-. 0-3' A/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000 S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1/1 S 114- <br /> 0;-A,.4(.A,<,-r <br /> 14- <br /> 0;-A,.4(;,4,<,i A:, 'Jc VALID 2 TO Z, i 5'/)�- DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> s�13yo /3r164 'Sr TYPEn <br /> (Mailing Address) FORMS S S/LV 1414 !R-I!? <br /> NOTES <br /> R-I!NOTES <br /> (City,State,Zip Code) <br /> gV�i 7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) . A 7/11 C a46'j. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 5&4!'u side of L,4 6 4-46 approximately 3-70 - fee mile C—� <br /> of F�' a ! A:� a -�0 0 , by performing the following work(description of work): <br /> E ca 'tG '", ��'► �/i"v IP <br /> ;-0 Lz 0'q Z71 &A&T- uta <br /> I`-2' tr`�Ca AJNiA i- ro— 0-4 i y' y.c� ' <br /> Work will commence on or about d "7 - 'L/ for approximately 10 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 /> Si nature of Applicant-Title Date <br /> M.ICENTRALSERVICESICLERICALIPtJMVWKIMASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (09113) <br />