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�'�rte_ �'.�i°•�i � ,�v:.i;'� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datey a .m. �� OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( 10005' REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE -I -1 DRIVEWAYS: <br /> C14 rZI`, r�r r y C�7�'���c��j VALID TO <br /> C <br /> (Applicant Name) STREET Lo er <br /> AREA (-p�_ QUAD �- <br /> 5-3L10 SJ°/;SA 7TYPE <br /> (Mailing Address) FORMS/W W IZ 5 <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) ; <br /> ATT A <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way o <br /> the 45,4s'T side of 4.0;V E)f• k'C"; �4at n�, �Z j�• _approximately Jd fee ile A�� <br /> Of i►*.��! r�„� G; :�J�ao� � .c'��, by performing the following work( escnption of work): <br /> F?x�►�2 F'i?caM c7, h�j Yal Lt OL+J Ar! C5cd5 ,Q <br /> �-, A(2-V <br /> 1 <br /> Work will commence on or about �7- -2 r - i y <br /> for approximately 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 te <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval <br /> J&c;Pr= <br /> Signat re of Applicant-Title Date <br /> M.ICENTRALSERMCESICLERICALIPU&SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />