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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �7 — I c6- 1 S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11605 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE. <br /> �(--0 1 QTCU 1� ,Q�1��/,�Sc� VALID 4-1�,-(� TO S-IS-6 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ <br /> AREA QUAD _c ' <br /> J��JJ i31�/u v1 TYPE dare <br /> (Mailing Address) FORMS <br /> NOTES <br /> �v��c��►2 , CA <br /> (City,State,Zip Code) <br /> " Z 5) 7`R's '9�3 876o, <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) A-T <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw Right-of-Way on <br /> the ��vtT N of 3► A b�©� Si. approximately 2 '7 c feet/ ile - <br /> of EM' l iZE side`ot 1-i cX i v fQ _, by performing the following work(description of work): <br /> -7 2 ; SA QGL41 PJ C-JIT I [-N co,lj, i-t i T Fj ri CSC!T✓ <br /> GILf?-Vt4-tG <br /> Work will commence on or about I - d 5 _for approximately .S f- I c 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 /> Aign <br /> 2_./0 lure of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPU&SV WKIMASTER PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />