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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date o I — Ul- Z D I'S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 6) REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID "TO DRIVEWAYS: <br /> (Applicant Name) STREET It <br /> AREA QUAD <br /> TYPE Q-1-A -51u"c" <br /> 11, (Mailing Address) ! FORMS SSJ)W <br /> k4aw Nl 0ciip1 NOTES <br /> �1 (City,State,Zip Code) <br /> (o — 503- 1 u•l <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -',_OU1Tt� side of itJ. SCAWICT approximately 5 Co fee mile 0 <br /> Of .- -Vkk SCS I LTE , by performing the following work(description of work): <br /> l t�STi�Vt. TtDtJ Dfr 1s, 1�'� '�o>� t��U�(3o` ! l{�ltT�©r► 'T <br /> S. 6kQe of 5;- t .TE- R•O 510E o� <br /> W. C--UW 2Q W tN)k Pct t K GPNt4 SST A:r 2G` t kJvAMM o tJ P� 6ECuiAD <br /> Work will commence on or about o t- 1-4— 1 S 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 /> Sig ature Wpplicant-Title Date <br /> M ICENTRALSERVICE$ICLMCALftB SV.WKMSTER.PSeXROACHIAEHTPEWT APPLICATION DOC (09110 <br />