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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> _ r <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> 6` `, t; — D �3 ALIDDATE 116 u 3t b- i DRIVEWAYS: <br /> (Applicant Name) STREET <br /> G / / AREA l�G _ UAD <br /> R49 TYPE 1 " <br /> (Mailing Address) FORMS 2. <br /> (�5,./ b NOTES <br /> (City,State,Zip Code <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> -See 4�{4t eco S e1�G <br /> The undersi ped hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Sdu side of lUev c Q a e r R co approximately S }.-z, feet/mile (-J e S t <br /> of ) cQ ,by performin the following work(desc iption of work): <br /> i 1'E' C/'OSS► It e,. �v r 0SJL' «1 <br /> olv /0' /4� Apo/P�! ro,�p G'C2K.a2n7e <br /> R�2 axe,- <br /> Work will commence on or about 1 o i for approximately 9 a 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 /> 77 U L <br /> WCENTRALSERVICESIGFWCAL'PUB,Ti,W*AWTER.PSEWROACI*.IV TPEPAIIT,-MCATM 00C(0 13) <br />