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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 1 --*> " OFFICE USE ONLY <br /> To: San Joaquin County JOB# 052. C,� REF# <br /> Department of Public Works APN CR# _ <br /> EXP.DATE <br /> VALID 1;'" TJ ! W <br /> DRIVEWAYS: <br /> (Applicant Name) STREET r.A /re e <br /> g .41 <br /> AREA ckda A QUAD E <br /> 410 _� (.a he TYPE �fl � art W tt <br /> (Mailing Address) FORMS T�Jp ,L�2' ��►,�� <br /> NOTES <br /> A q.67-2e5 `f <br /> (City,State, Zip Code) <br /> eI®e® 311 -7617 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the J5 side of 2 ,e rt rude- approximately 3 Ce4mile S <br /> of W !n 'n -1 a 72?tb-I to 2, by performing the following work(description of work): <br /> Work will commence on or about _�� 'za — zz0iL-- 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 /> Plar&t►oj- 9--/3 G 1-1ze G- <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SUWKWASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (09113) <br />