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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9 ' / OFFICE USE ONLY <br /> To: San Joaquin County JOB# #01005 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /5 14 <br /> v ,�/✓1f��' G�"���L' VALID �(� TO S Q DRIVEWAYS: <br /> (Applicant Name) STREET 0c, <br /> AREA f 5cAi o-L1 QUAD 56 " <br /> •�'��� S 5 - TYPE ` ,uP1=Fig G't1i?eJLy�ll�ES- IoUi2 <br /> r� <br /> (Mailing Address) FORMS <br /> NOTES S,4C Tb 16rwo✓E AN.* ^AAGC- <br /> (City,State,Zip Code) <br /> SSBI-�'y i - S csd8 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> /Xis A1- LJ--' <br /> �G��d uti �bG��'� cam✓/L L �� �r� �'"��� �.�'.�-/�-r�"J <br /> J <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 /> 5 DJ9y APAP GLa.S 46 Ar Weht VAy AWP AAA V, 0 - Ale L'�o5s•n� <br /> v ,+.E° .tiro✓E �¢,Nr,> ,P,E1�l„�9fE L' ix,l5. T�rJ�/ <�c.9Lo�/G'r7'3�'l sryJITS <br /> Work will commence on or about for approximately S 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 /> .cam-tic. <br /> Signature of Applicant-Title Date <br /> E.WUMV.WKVMSfER.PSE}ICROACFNBUPQUIITAPPUCATION.DOC(Gin) <br />