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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 64-1,5- OFFICE USE ONLY <br /> To: San Joaquin County JOB# ; REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> P�3 E CEoe6E �fI,55r,4W0 VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET S a j L L� " <br /> AREA - QUAD SG <br /> ',245 1*WWe&7_ dT SAnl /7�4A/GLSCO TYPE <br /> (Mailing Address) FORMS 141�/ 'a C/ fir, <br /> NOTES <br /> (City,State,Zip Code) <br /> 5/-2 - s &so <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE �97lfrC�YE/� ��,� o <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the side of Gov zy �iM�r approximately '7V 20 feet/ ile <br /> of , by performing the following work cription of work): <br /> COAW111 zr ?517 toe?77VO of poeECT1OAt+& 4j>oCF --neo <br /> PtAcJ#AtC A10. 5 PCE 04 vi-TJ AAI P , <br /> Work will commence on or about - 2Z -/9- 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 /> �l��L//�► ��y%(,Gl�- DE�sI(a�i/ �iA1�E,Q ( - ¢ >S <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPOBSV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />