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f <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Lf /z/2,01 L4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> _ EXP. DATE <br /> (Zr- M Z FOP- A 4 T VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ,�/` / n`� AREA QUAD <br /> r�G1.L1 Wt - TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ro c cG-0T(20 - PSS <br /> (�TAT- L 3 24 GS <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 /> SCE /'VAC1-171) clF v�� <br /> Work will commence on or aboutzo 14 for approximately 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 /> Signature of Applican -ritle Date <br />