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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date It 111 1y OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7.�Q C)7 Cl REF# <br /> Department of Public Works APN — CR# <br /> EXP.DATE J -(� - <br /> h�T�T I-them, �rc+r�S VALID J -(o (5 TO -I - ( DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD Al <br /> S 5 rj 0 l tv'e_ A\^e TYPE <br /> (Mailing Address) FORMS <br /> _ NOTES v <br /> �- <br /> ' (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ftp A�-� de-f 19 k7. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the &aA+ sideof a Sgcret fa �Jvapproximately !(Psmile A/oyfL, <br /> of W Pr nr_ Sf orn dvY, by performing the following work(description of work): <br /> (�) 4X4' spl,ce e a.,/d reeaw undo.f 4&,, _rlanh le acces c cs Y7-e deco <br /> L&l Af , 7?Feuc�m4yX9- c a vtjaw ��►r"-la li.*4 , 7'r rl W,c Con A-0I 'e �a ,ovf <br /> d¢rtt�., <br /> Work will commence on or about a o 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 /> ur of Applicant-Title �—Date <br /> rx�rrtrsxseancEsictecicniwuesvuKu,us�ps�+caoncH�xreEauRnrrucanor+.00c�s) <br />