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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 I 1" @"z- OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( 1000 5' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ( I - 1 � _/ S- <br /> ��r C6Y►5AC '0VALID ?-tb- TO - DRIVEWAYS: <br /> (Applicant Name)cic4 958VO STREET <br /> AREA L- lir r-lam <br /> 1X45 West G�wr�r 1,ywy TYPE � QUAD <br /> (Mailing Address) FORMS <br /> c, _ NOTES <br /> CA , a�2.Ot, <br /> (City,State,Zip Code) <br /> h4o \ '6�66-&Avg <br /> (Area Code-Telephone Number) <br /> ��tv..,• 7�,, <br /> ")i`+'C S=t dY4 YCrL. <br /> Sketch (Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_ 1L/ side of Eac+ Ver;�ag (kO0.d approximately 1400' feet/mile 6&15+ <br /> of A;Y\ Road 11�omIcco, by performing the following work(description of work): <br /> Work will commence on or about -24-- k 5 for approximately 2 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 /> 2 -I I- 15 <br /> Signature of Applicant-Title Date <br /> 209 -32ck- -?g25 <br /> M.ICENTRALSERVICESICLERICALIPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />