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(L <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date1 - 21- 1.5 <br /> � OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 I f,00 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ 3-I�'-/S' <br /> y6F'!J c-0 VALID 1-2 7-1,5' TO 3-(s-1-�' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 66QUAD <br /> TYPE Oq 6 r <br /> (Mailing Address) FORMS 2 <br /> NOTES <br /> (City,State,Zip Code) <br /> 425) -7?.5— 41 c'7-' <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 Highwa Right-of-Way on <br /> the6AGT1wW side of G&7716 8LAtr-G 74, • approximately Z I S fee mile SoyTH <br /> of fu_ L/" L,0 LIV kh. - f 0C-LT'Q P J_, by performing the following work(description of work): <br /> 3o2L- E12-oM .7--o,NT l�,;> L& T-o LGX,I in c9 CA Tv VA L4 L.l. <br /> Work will commence on or about 2-.;2. 15 _for approximately /0 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 /> J4Si4nabure of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPU&SV WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />