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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6:1—I C� ' ) 5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> L EXP.DATE <br /> OC CDww+tiw� Cc.5 v�S VALID �� TO Y—f - DRIVEWAYS: <br /> (Applicant Name) STREET <br /> Ste koo AREA L, QUAD Al <br /> TYPE &Or <br /> (Mailing Address) FORMS <br /> NOTES <br /> C�KGrove, C.� �►5'�S'S <br /> (City,State, Zip Code) <br /> 9116- 70�b-`le0b <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may b submitted) <br /> I <br /> I <br /> I <br /> GoRr O <br /> EVer,"ne Cl ski <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighwRight-of-Way on <br /> the side of E \k,(-f--e- CT approximately !S0fe( eY ile '5wR, <br /> of `�e�•�\ev Ct by performing the following work(description of work): <br /> q {U FT �b recfa-c_1 j�v e c-c ros-N K) G�av, A,% I-,, �-o <br /> E t'e�OrC Low.G, S-,+ -S¢lv,G2s 5 I- 0-�s <br /> Work will commence on or about t S" for approximately IL 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 Sari Joaquin County and subject to inspection and approval. <br /> Signa f 49ticant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />