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1 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6,/ S OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> r EXP.DATE 10 15 <br /> QL( <br /> Rc U` �/ee-�✓.C VALID TO lv DRIVEWAYS: <br /> (Applicant Name) STREET <br /> I kP,_AREA R <br /> bylJ � <br /> Z it/ TYPE — QUAD Al <br /> (Mailing Address) FORMS lee <br /> u <br /> qs--Z'V NOTES <br /> (City,State, Ap Code) <br /> _ Z-16q- 3&-17�, 7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 14-rTj4 SKt�7 �It <br /> 111�n (' ' llal SZ U <br /> The uZ <br /> igned hereby applies for permission to excavate,construct and/or otherwise encroac ,on County High Right-of-Way on <br /> the ��� side o _ 11 ems- (?�I <br /> approximately � e mile l���� <br /> of - vc Grp,. C l ,'.� r ,by performs the followin work(description of work): <br /> Q u f�1 4 t* cal t', <br /> Work will commence on or about <br /> 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 /> 61Lqb <br /> Signa scant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMfr APPLICATION.DOC (09113) <br />