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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date //o? /is- OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11po s" REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3 t t S <br /> VALID 2 2 t S TO3 t /S DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA L.aa t QUAD A/W <br /> TYPE T 6KIew Y44 (P/& Pt�cEME ' <br /> (Mailing Address) FORMSrS�EUpG _,e p/r Als <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> *,I/p rt*M1�,�¢1 neEa VY.'5P9^/ Z:*Pg4VW L'dunnY��25oti%e1EG <br /> '5 <br /> 'Q <br /> 2 L Er- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HigRight-of-Way on <br /> approximately /_/0 fee mile <br /> of J�.cclqs Re,/- D by performing the following work escription of work): <br /> �xc���/��•/.—c l..✓t�e�:,�.G��/bac �a/�JJ :v !-?EPi.Acc� �XiS�'-iy�- GT�ic.�,gtn Cu�L'Li2i <br /> ZA2 !/,79,-27z72//dG ic% <br /> Work will commence on or about p1 i 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 /> Signat re of Applicant-Title Date <br /> YAFORMS&TEMPLATESIENCROACHMENT PERMRAPPLICATION.d.(08108) <br />