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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date , ') 2 - y OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE C,_ 2&t<- <br /> C DC_CID V\.^✓-,0""'%ca,i')L' VALID :7 - p TO 1 E DRIVEWAYS: <br /> (Applicant Name) STREET <br /> Sfie \0o AREA L( nil-A+�D NW _ <br /> ZZU 4 �cyS�L �c� TYPE <br /> (Mailing Address) FORMS iAtiLd.). DZq <br /> NOTES <br /> C1� G,ro�e , C<- 957 S-S tib u 'psz <br /> (City,State,Zip Code) 6kS -k-, i L <br /> C1 i, - -�08 - '�00d <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) I 2l <br /> o- `T F-t <br /> 121 FT <br /> LlI <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on , <br /> the 5«�'�. side of M ettt er- RoX approximately I QLVp ile r `ir <br /> of N. i}AP\ CL, <br /> , by performing the following work(description of work): <br /> ,I f Stc-eek Altz 13o rye to C- o r- Co <br /> Work will commence on or about 12-1'7- 1 `\ _for approximately 2 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 ve in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signat pplicant-Title Date <br /> 1(/o - <br /> M:ICENTRALSERVICESICLERICALIN0 SV.WKVAASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) ' 0/�- <br />