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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: l <br /> Date -1 - Z- 2 O I �i OFFICE USE ONLY <br /> To: San Joaquin County JOB# _� >�� REF# <br /> Department of Public Works APN CR# <br /> I_ 1 EXP.DATE O — <br /> t VALID `i p f ATO -- � DRIVEWAYS: <br /> (Applicant Name) STREET ( _ <br /> i 1. <br /> AREAftOLQ�59-- <br /> TYPE _ <br /> (Mailing Address) FORMS S h u)• EAG <br /> NOTES T� <br /> ere. 55307 <br /> (City,State,Zip Code) <br /> 2 0-5 76-876 Cell Zo -678 Z7 9 9 <br /> (Area Cod -Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the We -4-Ce, side of iii r2ck QJ i raco approximately 1-(Q ' feet/mile <br /> of , by performing the following work(description of work): <br /> Nara tori i7 z1IN 4 1 <br /> IJc )n Z L e c E r'1 �. e s r��e 3;ec( R, bey,) <br /> d <br /> _c�2rny -78 Lo Cus-Vcrv,eS occs � � n CLs ( s) <br /> Work will commence on or about Z o for approximately :7y 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 c rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -� <br /> S' ature of Applicant-Title Date <br /> t:.1CCNTRAlSERNCES.CIFRICAL1Pl13.SV.N'Kl'dASTER.PSIENCROACH!,IEN7 PERl.!IT 1Pr IICATiON OOC (0 113) <br />