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APPLICATION FOR ENCROACHMENT PERWiff <br /> PLEASE PRINT: <br /> 14 <br /> Date J J - 0a OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7���s Z REF# <br /> Department of Public Works APN CR# <br /> r> r _ EXP. DATE <br /> f'- VALID <br /> TO 7-I-1S DRIVEWAYS: <br /> (Applicant Name) STREET Ss Qy R <br /> _ ] � AREA QUAD <br /> Czt2t 0i�( t�i�` ru.:�rJ �'j�G'� TYPE S <br /> (Mailing Address) FORMS <br /> WW Rz� <br /> NOTES <br /> CA <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> i <br /> Ct <br /> 1v Ile ri A4. <br /> r <br /> �J <br /> V F/ 6 <br /> J <br /> The undersigned hereby applies for permission to exc vate, constr ct. nd'or otherwise encroach on County Highway Right-of-Way on <br /> the W!.Sf side of �• I�AGfCLClAJ..xS1cg.� approximately feet/mile <br /> of _ by performing the following work(description of work): <br /> C�Lvv�� . C14- La e <br /> Work will commence on or aboutG L= �/ 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 /> Signature of Applicant-Title / /Date <br /> 6-X %"'Q 7 6 Pt F, 6 r", <br /> W:ICENTRALSERUICESICLERICALIPUB-SV.WKIIdASTER.PSIENCROACHIdENTPERUfTAPPLICATION.00C (09113) <br />