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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> LI OFFICE USE ONLY <br /> To: San Joaquin County JOB# Soc `?1 REF.# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> Cfll_11= 1Z/)l A 1 VALID I "zoIYO Z2- Zc�c� DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> AREA w� <br /> �0 E QUAD N <br /> . QA F,9 L� 1.E Ste. TYPE �� <br /> (MailingAddress) FORMS S. <br /> NOTES <br /> (Clty,State,Zip Code) - <br /> /ao�11J , y --� <br /> -'(Area Code-Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> l mo—P <br /> 7 l <br /> The undersigned hereby applie ,for permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the iv'E � c: side of lC,_-ktiGtc 7 ; <br /> of r.^`t'en «t Ql �rv� ,, (��L of jt.- c 1 fie mile W vr4 <br /> by performing the following work(description of work): <br /> IA'Y))� <br /> .e�� t,�. <br /> + �i ,tib A k -) <br /> WON( <br /> Work wdl commence on or about <br /> for apprmely/ o i ______days. <br /> I,the undersigned, certify that I am the owner of the respective C/., j 1 y <br /> work described above in accordance with the rules and regulations o San Jo qu n qualCo my andsubjectto inspection andapproent the owner and agree to oval.the <br /> / . <br /> ��ignature of Applicant-Title <br /> ®ate <br /> FAICENIRALSERNCEMCL.E21CAL1PUBSv.WIITAASTEPPMCROACKMEFRPERMRAPPLICAI,,,,)00(09,13) . <br />