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t o q J i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 'I IL12of L OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP, DATE IZ— k—2U(H <br /> LILA(Zi— Af4l VALID _ .z / TO ?�^ 2c�l�c. DRIVEWAYS: <br /> (Applicant Name) STREET n& <br /> v-Y <br /> AREA ;"tGLtC_foV`.QUAD ' <br /> 210G <br /> AMUE TYPE T 1 55 t"C> G�1rpw <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> PrSD 1�C � L �►-- 5 <br /> >PA7 JZ4)� �32-40 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> DCSCEt00QQ CIE <br /> Work will commence on or about zn 4 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 /> I <br /> Signature of Applican -title Date <br /> i <br /> .; .E'.I IAL:E^N:CESTLEPKAL'P.;9 3V'X'AASTEF:�Er.,:P"_11.C1-IP4T r•EPP.IIT-P-UCATI.,N JC: {^jl I":) <br />