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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1L3//20X1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# oo � REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE IN <br /> %�e Souse 6.oup. Inc- VALID 2.Z1-ZvIjTO - -20lu DRIVEWAYS: <br /> (App scant Name) STREET Ohs 96� <br /> AREA QUAD ; <br /> TYPE bayP_ x,- d <br /> Mailing Address) FORMS to k3 <br /> NOTES <br /> Gass r/tii/�„ cA 95' <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the-s-o,,44 side of C�,�OC�U�e%{ Ro�� approximately /.z feet/ G.cs7� <br /> of ��4- 76-,- 12.1. by performing the following work(description of work): <br /> TXr- e Lawle— u7- on,- �errsoa.4... rv:/ /io�,>,� 7v� ��c �co/%cfiun o.n,S <br /> G�0". ej aw der Sa.,�o/e s. �/tec/r �•e/vsecl cv✓r�s _ f'ncrrac�i.Ke tee �t3� 1 u�o( �iarin� {cam �i0//3Z <br /> _711C0 ±"7 <br /> /�UliilS L.i �� /,e C.Male�u �o ivluYc�i Sus 7GeC fuh {vNt <br /> -� i <br /> Work will commence on or about .u,,- /9 0/1/ for approximately 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 /> "4 521e,-4,4 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSER'ACESICLERICALIPUB-SVWKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />