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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 61 I yea <br /> Date ,T_ �, ) OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# , <br /> ,� _ EXP.DATE 10-31-20 t <br /> L�l Tz (�PA)1 A \V V f I'EIZ n' (Z ) i C,E VALID -S 20t,4 TO 10 zo(� DRIVEWAYS: <br /> (Applicant dame) STREET <br /> AREA1oE . i;.AT" � 1✓ ST TYPE � Ov--QUAD <br /> (MailingAddress) FORMS C <br /> NOTES <br /> (City,State,Zip Code) <br /> to Y -' 5,3 i 1 <br /> (Area Cade e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> —4- <br /> The undersigned hereby applies fo permission to excavate,construct and/or otherwise encroach,on County Highway Right-of-Way on <br /> the side of approximately fee mile Ooh <br /> ofby performing the following work(c escription of work): <br /> n(o 0 Ate+ 10 ,30 0(3 <br /> tt(' CID <br /> Work will commence on or about q IL1 for approximately days. <br /> �5 l4 <br /> I,the undersigned,certify that I am the owner of the respective prope ,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 C `, pate <br /> Fk%cEFlIRALSEmcE9cLmeAL,Pumv.wvAkSTERP51ETCROACHA7ERTPERAFRPPPLICATIOFLOOC wi3} 1 <br />