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�1 <br /> (6c <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dates j-t LI".2d/y OFFICE USE ONLY <br /> To: San Joaquin County JOB It 0,M_5— REF# <br /> Department of Public Works APN CR# <br /> / EXP.DATE -1-20 l <br /> VALID S-/ -za/ T ~]-(Ze Ly DRIVEWAYS: <br /> (Applicant fame) STREET <br /> / AREA wQUAD E <br /> TYPE VI\'Ok W <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> �Zy-S76--0 76 G /--eW <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> f�; top <br /> { <br /> I ;del <br /> ` <br /> 1 <br /> �P�I roP 5-W p,+ Ic 5P�ti <br /> L4 Z6, <br /> 6 5 <br /> �vu r <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- So���� side of 7i l Coct�f approximately mop" feet/mile <br /> of by perfgtming the following work(description of work): <br /> D;a �„n�, z s� 1"Ce r��} f �so�� -or Cage f-Cr>ar"ZS <br /> Work will commence on or about -1 G� - 2 0! for approximately 3a 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 /> 'Signature of Applicant e Title Date <br /> ,/..(CENTRALSERNCEMLEPJCAL1PU3SV.WKVA,'STMPSIENCROACH�IE11TPERAfITAPPUCATIOHDOC(0%13) <br />