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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: � <br /> Date N d e*��r 24 ( <br /> , 20 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 02)Z REF# <br /> Department of Public Works APN CR# <br /> �ly� L EXP.DATE ��23- 20/� <br /> 1 'I�IerS d 441%% CVkS'e7'c. c 'Un VALID -3- TO I,1.-23--��� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> �Gv �Gr�j. �dC g�u� SGe IW TYPE <br /> (Mail in' Address) FORMS <br /> 9S 8,? NOTES <br /> (City,State,Zip Code) <br /> gra - 2169 - 7,7 �-v <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See /a-t-4-< c 1n C"( <br /> SSP la- &t< G 1-2 eiC S Ch e(c. 142 <br /> The I indorcig ed hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the oto Sa side of W!1 c I , /2 _approximately feet/mile <br /> of , by performing the following work(description of work): <br /> r i P c r c� <br /> iwZc 4 ti,�ti Ccir- �a Kac.. -e <br /> lcia.r ft . <br /> Work will commence on or about JAwcaft 'r, Vl 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 /> t-�- 11 126/I el <br /> Signature of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPUB-SV.WNIMASTER.PS%ENCROACHMENT PERMIT APPLICATION.DDC (09113) <br />