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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 o t 3 — 2-�/! OFFICE USE ONLY <br /> To: San Joaquin County JOB#. 7y („ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> PM 311 70 C( 01, > VALID J61,1115- T6 DRIVEWAYS: <br /> (Applicant Name) STREET C&Irffo t A1/e_• <br /> AREA 05466 fc" QUAD 0 <br /> P� 4!® TYPE (3)-gpj( (401e3 ( #,,t e fe stf <br /> (Mailing Address) FORMS S trr,a, , z� Trtcd, tf" ; ,cy <br /> NOTES <br /> C A <br /> (City,State, Zip Code) <br /> Ll40- -418 -- IMS 7 <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 1[10-t-K side of 23 D 3 C`,Ar 1-t 0 Ay approximately 2 60 smile_ S <br /> of CG u.div A t u b ,_ by performing the following worst(description of work): <br /> I y i t 1 <br /> Work will commence on or about �9— ,w a- :�2-®B. 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 /> - eL-f-- Plerw�,'J- ea�rdl'rwt) -3 G 1,5- <br /> Signature of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPUB SV.WKVAASTER.PSIENCROACHME14T PERMIT APPLICATION.DOC (09113) <br />