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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 ( odo 5 REF# <br /> Department of Public Works APN _ CR# <br /> ' EXP.DATE -711114 <br /> VALID <br /> TO DRIVEWAYS: <br /> (Applicant Name) STREET L�,yc� i 5• ko <br /> AREA S�C1 C QUAD S S <br /> TYPE <br /> r <br /> (Mailing Address) FORMS <br /> /'i _ NOTES <br /> G C?,�'c'S'_ �C_ti Jew <br /> (City,State,Zip Code) <br /> 0 3-7,(, -o�1766 /4 01/ -6;pe 2�7 7'�' <br /> (urea Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to xcavate,construct and/or otherwise encroach on County Highway-�,Right-of-Way on <br /> the �r �� Solt 1 side of Le'ln,1•r s rL'A approximately V ' etlmile <br /> of by performing/the following work/(description of work)• <br /> Work will commence on or about 3 2 for approximately ?- z = 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 d=of <br /> with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> le pate <br /> PA.ICENTRALSERVICES1CLSICALIPUBSV.+A'KV,'ASTER-PSIENCROACHAIENTPERh1RAPPUCATION.DOC (09113) <br />