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co I'l <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# ((fin REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ( 0-3 - <br /> �p (veF�U Qo) VALID y-21-1q- TO �( � (- DRIVEWAYS: <br /> (Applicant Name) - STREET R_ „tel PCA <br /> _ AREA LoCkef1 ed QUAD IJIL—: <br /> TYPE <br /> (Mailing Address) FORMS s SIWW 2 Z I <br /> NOTES <br /> L/✓6-17 , C—A �71q'-5SO <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) C 14e <br /> The undersigned hereby applies for permission to excayate,construct and/or otherwise encroach on County HigPfee <br /> Right-of-Way on <br /> the N ` side of �4�bT i�M� approximately bile GtJ�i <br /> of W t 6>i-1 , �� % �G�e 1c '�t'.9 by performing the following workription of work): <br /> !tea L'r'.j L� "�v�PSI �C? IA.) ' Piz L& m / Z-7 t/_3 13fi.*1 11 15 T Z1b <br /> l/Ua1 At-L [n -Z_' r—o'J,iN T F-0tL e4Ty <br /> Work will commence on or about -• for approximately /0 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 /> Asi u of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUR SV WKIMASTER PSIENCROACHMENT PERMIT APPLICATION DOC (09/77) <br />