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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / �' ` L/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 0 2 7f REF# <br /> Department of Public Works APN CR# <br /> _ EXP. DATE <br /> VALIDZ3-� TO (`-I - DRIVEWAYS: <br /> (Applicant Name) STREET P �{ <br /> AREA j uc V QUAD <br /> r Pr-f- TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> ��:CPs-fz� , c A 9"5-, Ll <br /> (City,State,Zip Code) <br /> 2GC1 !�-7Sr — '-7,3 <br /> (Area Code-Telephone Number) <br /> Y'b 37 z <br /> Sketch(Detailed plans may be submitted) <br /> .S •F-e- /q t ( (iCk_P_,14 6 L,�S P� <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 Pp,* rcy)n Qa approximately �p-._j--7p ee ile L.aaQ -t <br /> of Ura /V i r a 1 by performing the following work(description of work): <br /> -PScr,. ccncl X2 (41C e - i<r r✓e �i� o�/J ��on--) <br /> Work will commence on or about �r�a� /J tf _for approximately 5 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 /> �2_ � <br /> Signature of A -Title ate <br /> M ICENTRALSERVICESICLERICALIPUB-SV WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />