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1 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# j 1 wo" REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ <br /> 0 — L Itz.- VALID 2 SI T6 ZZW4 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA racpM a QUAD " <br /> '23 -29 S. JT, TYPE IEMA V660 CA SLIAL <br /> (Mailing Address) FORMS <br /> NOTES <br /> W_ 7&-)Ae 1Z) <br /> (City,State,Zip Code) ✓-'Ob ,� /f%1�9J1 <br /> J Jr� -4}'o/ - <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 19 Z- T —C►- 4- r"o <br /> The u ersigned hereby applies;or permission to excavate,construct and/or otherwise encroach onHighway Right-of-Way on <br /> the side3of 6960icTrEA2 ,G'D� approximately Cod feejo <br /> of ,by performing the foll ing work(description of work): <br /> Work will commence on or about 2 14 for approximately a, 7 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 Applicant-Title Date <br /> YV WAS a TEMPIATES04CROACHMENT FEF M- APPUCAWN.d-(08109) <br />