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P ? J1 2-6`/3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f' OFFICE USE ONLY <br /> To: San Joaquin County JOB# ? Q Z REF# <br /> Department of Public Works APN CP.# <br /> EXP.DATE <br /> -C/ca r�G[/c �T�1 zs. f Cj VALID 6--Z:_> /,5- TO 8`JS 1S DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS �l <br /> NOTES <br /> Sa-YZ fZ�zn2�2, C'9 �/�/S�"3 <br /> (City,State,Zip Code) <br /> yes z'/4 // �cz� 1��P L <br /> (Area Code-Teleph ne Number) <br /> Sketch(Detailed plans may be submitted) <br /> X_ t� ears e e GlJ-�c�c �z�Gl 7 1,-�,-/'YUFiawt� jai c_ <br /> C Cglf1- 7 <br /> ie undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> e side of approximately feet/mile <br /> by performing the following work(description of work); <br /> 9 rs n.7rr�n s ivLo to Ax �Lr <br /> 5 <br /> 4U251 Lpq <br /> �1ce <br /> ork will commence on or about for approximately <br /> days. <br /> :he undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> >rk described a rraccordan the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sign4tyj&d Applicant-Title --� 'S _/5 <br /> Date <br /> NTRALSERVICESICLERIC.4LIPUD SVlS'KN.MSTER.PSIEIJCP.0.4CHI,1EIJTPER691TAPPLICHTIOIJ.DOC(09/17 <br />