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-SAA JQAQv /A/ (fouA/ Y <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date C5 e6 / /y OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> / Q-2 (� — S10(7 Z 0 e9 VALID ATE I-- <br /> r _/!j TO 7. J DRIVEWAYS: <br /> (Applicant Name) STREET PC IIV& n s <br /> AREA Lad,- QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> L<)8-Sl ,S�erQ.Ke� � oW 9��0� <br /> (City,State,Zip Code) <br /> 916- & ,Vz- aSg6 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See Q e <br /> The undersign d hereby applies for pelnission to xcAvate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the weS side of Ve e es 4? approximately SO feet/ea+l4-5z� <br /> of /r, IV " CCU , by performing the following work(description of work): <br /> ftp/Q c,� Qx•' �:h 4 3�t s � S pl%c.e ��r �v%�i 5��6'1C 8�C'' $,�/i ce <br /> box- <br /> Work will commence on or about f" for approximately- b�7 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 /> n-l"-OUCL"40" 616/Z.2.) C/ <br /> Signature of Applicant-Title Date <br /> �exV';d LP,4i;e-4, -z>DuI G PGE. CoM <br /> MiCENTRALSERVICESICLERICALIPUB-SVWKUASTER.PSIENCROACHMENTPERMFFAPPLICATION.DOC (09/13) <br />