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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9-1-o OFFICE USE ONLY <br /> To: San Joaquin County JCB# AM M REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE 0lei i F, LAdq <br /> C- 1' :52)bj J VALID J / /q TO J Q DRIVEWAYS: <br /> (Applicant Name) STREET ARtouS 3?s to,vo rP?in4nTlb� <br /> �N AREA ,lulu: QUAD uUO <br /> �-11 TYPE t <br /> (Mailing Address) FORMS <br /> - NOTES <br /> (City,State,Zip Code) -roaE 1 oom q10oAm-a'-0qPrA <br /> :cav Prh—r o t eo P, A►zz Qc+,b r 9 <br /> a��I- Yl�v�' �J �� rT�•oNl, �;o�EIM,_ ZSoo <br /> (Area Code-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 side of approximately feet/mile <br /> of _,by performin the following work(description of work): <br /> PD P, i)F 5 L k SJ- 1-12Lus-9 Avg <br /> E ' t <br /> 12 1 <br /> Pry �5r 1NClAl� Q !��l 9:D�,a�Ir! <br /> J.,Zp- Pin <br /> Work will commence on or about /tJk—I for approximately 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 /> a. tq1LUA Q ' 9-1-/21 <br /> Signature of Applicant-Title Date <br /> M,CEMPALSERNCESkL'ERICALTUBSU.WKWAST-LRPS ICRORCRMEN7PERMRAPPLICAT10H.000 PWJ31 <br />