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APPLICATION FOR ENCROACHMENT PERR41T <br /> PLEASE PRINT: <br /> Date ._ Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000�— REF# <br /> Department of Public Works APN CR# <br /> i- EXP. DATE <br /> —(- S \ �c n s ri VALID -(_n-t6-(4 TO 11- i 4- DRIVEWAYS: <br /> (Applicant Narrne) STREET !it nfs{q —9C . t <br /> 1 AREA d QUAD _�F <br /> Lo-eTYPE qer� <br /> (Mailin Address) FORMS 45/W W <br /> NOTES <br /> --- - 5--- - - -- -- ------- - - — - - - <br /> (City,State,Zip Code) <br /> 3 <br /> (Area Code-Telephone Numb;r) <br /> Sketch(Detailed plans may be submitted) <br /> �C <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the CE 1.1 a tJr 5J side of tZ A <br /> of approximately__ Z S feet/mile <br /> by performing the following work(description of work): <br /> c <br /> L+P Y 1i 1 L.� l I?-C- c $5 C. -A 0 rL 1CaC E Ie o n <br /> Work will commence on or about o ;7c)I� for approximately d 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 /> 1workescribed abo in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> gnature of plicant-Title Date <br /> FI:ICENTRALSEFMCEMLERICALIPUBSv.WK AASTERpS1ENCROACHkiE11TPEFAIITAPPLICAT10r100C (09113) <br />