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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 000 5 REF# <br /> Department of Public Works APN Zp CR# <br /> -� EXP.DATEDRIVEWAYS: <br /> r 7` <br /> vrt%i�a..�t��-, es �t., �0�-,5'��-• c`�'�,. <br /> VALID <br /> � -7 ,- TO <br /> (Applicant Name) STREET -mar p 0 C� <br /> AREA ES CC4O <br /> � yl QUAD S <br /> TYPE 8 <br /> (Mailing'Address) FORMS <br /> 1-1 <br /> NOTES <br /> -1IV, <br /> (City,State,Zip Code) <br /> 20� Ldp _ �.Ih2 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> U 't1 <br /> S COt VNA/ Tom.4a.C <br /> 20 <br /> 20 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw Right-of-Way on <br /> theWorlkdS-wA1, sideof A4eA✓I#)OS <br /> Of /2"` �G ,�L � pGc✓G approximately_ O fee ile <br /> a j by performing the following work(description of work): <br /> YG d r {F 0 ✓C r C R^ u �ouzh J\de -ic' <br /> AJt,,+I, 51JC C, <br /> Work will commence on or about_ 3o -2o> for approximately days. <br /> 1,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 /> 12 aI) <br /> Signature of Applicant-TiNe. _) Date <br /> K'CE.4WLSERV..CESCLERICXAPUPSV.WKU4STERPS%El4CROMHAIENTPERLHTMf11CATIOrI.000 (Clip) <br />