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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date V 1131))4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 D S Z REF# <br /> Department of Public Works APN CR# <br /> , ) EXP.DATE 1()-3 ( <br /> VALID TO (y -31- 14- DRIVEWAYS: <br /> (Applicant Name) STREET /aIL,C)u s 5�fpc 0�1h sf e ets <br /> AREA S-FrJck-I-oh QUAD 15; <br /> $o W m 60P,60P, C-Wi Yo A F-JD TYPE <br /> (Mailing Address) FORMS S OAzw <br /> & �,�^Qs NOTES <br /> (City,State,Zip Code) "�7 U <br /> X57.-'- -5Z4 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> (,Lx,�-Cn (5-5&T-3 TEM IT' iDvi <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 /> Cr�'�)r�la fits AsU.dE�o- ly✓ C:RWb Ia <br /> •�ia�,u <br /> isms t-D ' ►©A <br /> Work will commence on or about S S2,014 for approximately- AWK41Y days. <br /> I,the un rs ned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work e a ve i cc ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> r tule of Uplicant-Title Date <br /> IA,CEI\TRALSERLICESICLERICAL1PUE-SV.IrlYHl�ASTER.PSIEIJCRO.4CRI.IEIdTEEP.LdITAPPLICATION.DOC (03113) <br />