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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />Q. icL4-Ayor CC,.S�7CVC-+,oma lN c <br />(Applicant Name) <br />(Mailing Address) <br />S5 Z - <br />(City, S ate, Zip Code) <br />Sao. 8(o4. 3Co2y <br />(Area Code - Telephone Number) <br />Sketch <br />Sketch (Detailed plans may be submitted) <br />Sri pick is <br />OFFICE USE ONLY <br />JOB # 720:7:7 REF # <br />APN CR # <br />EXP. DATE <br />VALID 41j711'4 TO�_ DRIVEWAYS: <br />STREET . <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />QUAD IAZ5 x <br />Rg-�A - <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />thew 4 S side of tpw^ z A 14vi approximately _ Rood feettmile <br />Of " , by performing the following work (description Jof work): <br />4 �l b 1 T <br />o 1e.�.cct <br />Work will commence on or about for approximately 3d days. <br />1, 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 />1 a w w�-,r' %z%113 <br />'Signature—of Applicant - Title <br />Date <br />M:ICENTRALSERVICESICLERICAL)PUS,W.WKVAASTER. PSIENCROACHMENT PERMIT APPIJCATION.DOC (013) <br />