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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' l L OFFICE USE ONLY <br /> To: San Joaquin County JOB# (� �\r•Y.,�,t REF# <br /> Department of Public Works APN CR# <br /> N iZIS J'�/z/2 EXP.DATE <br /> C � 5 Nc� VALID f-Z TO -11 DRIVEWAYS: <br /> (Applicant ame) STREETS <br /> �Sj � AREA AD <br /> S3�Q L/SAS �, TYPE <br /> (Mailing Address) FORMS S�S <br /> NOTES <br /> Cr 1yE)G�1&tz61 C?g '9c/,550 <br /> (City,State,Zip Code) <br /> 12 5) W3- q8'-77 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) /V—ITtnCNg <br /> The undersigned hereby applies for permission to excavateonstruct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 401ZT0 side of 1f14 FP6wS X-IS, approximately 2 ee ile EAST <br /> of ff1C.V,4 ft "tiu S BLVD. , F96yu C N G4r-j?,by performing the following work( escription of work): <br /> Bc?gjc- F-Ao M �iN i 7>0 4.6 ON Ch1 LAS Xb A-)d gly To <br /> /1/GNA6[. C-Q/UL-!S BLVD, <br /> Work will commence on or about - for approximatelyC'7 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 /> a re of Applicant-Title Date <br /> MICENTRALERNCEWIRIC LVU&SYOKUUSTERP4ENCROADAIENTPERMITAPP=TIONOOC(Vt]I <br />