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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: /l <br /> Date -z o 14 — — <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# _1 o0o �j REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> VALID SA 5t TO 2Z! /14 DRIVEWAYS: <br /> (Applicant Name) STREET /✓�a,_� 4,�tnr br <br /> AREA 1yv G�c �i QUAD 5 <br /> TYPE - <br /> grP <br /> (Mailing A cess) FORMS <br /> ----Gres _. _-1_S`��G NOTES — - - <br /> (City,State,Zip Code) <br /> 20�--576 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the 64-5,11t BJer side of WAc A#k1'ut- i�r approximately . O feet/mile <br /> of , by performing the following work(description of work): <br /> cry 2vr! aR� r�+r�► Z vZ� Z 2-0 �c -Adkil L)v- le cc <br /> v At! ie lee or7e; s-c►otce w,2i <br /> Work will commence on or about —for approximately .1 a 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 a ove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> �PVJ9 F,7 r Y�e v-N Ll -Z 2-0 ILI <br /> ignature of Applicant-Title Date <br /> ZO1- 678' zir `7 <br /> M:ICENTRALSDMCE-lCLEICAL1PUMV.WKV=TER.PSeCROACHMEIJTPEFirr APPLICATIono0- (0 lq <br />