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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: c 03 0 )`T <br /> Date �o - ` � - a o l 1 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 00 70/ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE (-_� 47 <br /> 1 <br /> VALID I (-Z(.-'¢TO � ` =(S DRIVEWAYS: <br /> (Applicant Name) STREET 11[q�prlo0 ROt <br /> (� y�^�/� AREA S�oC QUAD _ <br /> 5555 E. 011ve. A�/2 M lW TYPE rCoohmil Qeyrces <br /> (Mailing Address) FORMS S VV 1t/ <br /> k: 01 CA q37 a7 NOTES <br /> (City,State,Zip Code) <br /> SEA- L454 - qqW <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ck-�+a, ch ed dravvin S <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 /> p r>t r c Y 1 by performing the following work(description of work): <br /> �avcey' I -4- ©r t- A\ie �NC e e. S S <br /> Ea ) m 2 rtO Ge, YIJ e.r <br /> Ca Y--\ d cc, n n 6, e, <br /> Work will commence on or about - Q 14 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 /> I o- 12-- (a <br /> Signatur of Applicant-Title Date <br /> lE--nC I nee- rl noJ 76\d r,-\-% n I <br /> M.ICENTRALSERMCESICLERICALIPUB-SV.WHIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />