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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4_31 o OFFICE USE ONLY <br /> To: San Joaquin County JOB# jj0o5- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ! <br /> ,-061py-W J/��S l�� VALID T p DRIVEWAYS: <br /> (Applicant Name) STREET GL nmTol.l AJ6.SoLrrOl Mato A49! <br /> PC) AREA P_1 Poi N <br /> QUAD E <br /> lJ�( TYPE -M MP. ROAD C. Osu RE <br /> (Mailing Address) FORMS <br /> C 9s3�� NOTES <br /> � Lo THESIClES 57k t IOK oN <br /> (City,State,Zip Code) g a 1 q ;ooA k. Td <br /> (Area Code-Telephone Number) <br /> Sketch e(Detailed plans may be submitted) <br /> Q� n <br /> I <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 approximately feet/mile <br /> of by performing the followi� rk(description of work): <br /> CoS�re O-F Cli. rw\, (t/Q Shu h £ McII� {eve- -{�� ��''lC� Rint�wv <br /> ISE. S VH Ny,F . G t V:E, t2OK-) <br /> Work will commence on or about for approximately 7,1,aVA04 To S 6 A4. 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 /> & hl)n'A, - &�,� & <br /> 4�I f <br /> Signature if Appl' ant-Title —1 Date <br /> MICENTRALSERVICESICLERICALIPUBSV.WK MSTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (0903) <br />