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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ILI OFFICE USE ONLY <br /> To: San Joaquin County JOB# - ( ( U 0 0 S REF# <br /> Department of Public Works APN CR# <br /> -1- <br /> r-- EXP.DATE 7 �/� 4 <br /> Y 15 f� C®�S r��L 6VALID 5Z I ( TODRIVEWAYS: <br /> (Applicant Narne) STREET ��f I <br /> t <br /> AREA L-QCkpfQUAD IV <br /> 4t:C. ' rte.(IE TYPE <br /> W <br /> (Mailing Ad ess) FORMS W W 9 <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code- elephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permis n to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Atr-A-t South side of I= - 31 k�0 approximately 100' feettmile <br /> of , by performing the following work(description of work <br /> 0 1AQ- -Zv✓r c, 3a UA Acr (-dCtCK. tram ' 1L-Iq - LI I Ll I C= t3 <br /> �q ee 1c,Cc ' <br /> ioC� u � le le tce <br /> Work will commence on or about 11-211- 201 for approximately_ S 0 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 describedabove' accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> SIdnature of Applicant-Title pate <br /> a0`i`G- 78 -.2719 <br /> M:ICER'1RALSEROCES5CLEPJCALTUBSV.WKVMSTERP51ENCROAC kiEt7TPERAfRAPPLICA'nOMDOC(09113) <br /> 1 <br />