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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 ( I 15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# /QDO$� REF# <br /> Department of Public Works APN CRA <br /> / EXP. DATE j <br /> VALID I'S' TO <br /> (Applicant Name) l DRIVEWAYS: <br /> STREET <br /> AREA Gfit QUAD <br /> 2G. �/+ �r•.n�.� ��K ri/� TYPE K aC Sc u3 - <br /> (Mailing Address) FORMS <br /> NOTES <br /> DeC UC OA <br /> (City, State, Zip Code) Q <br /> »�� s <br /> f2or-,� Sa'3 - 23 <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 side of approximately feet/mile <br /> of , by performing the following work(description of work): <br /> _G�.-®S� �ca•^�ca-�rS c's�' QvC;,"�--✓�torr '�'LX -ft7 ►c-v��uu --t-tt..�� <br /> TCay�^51✓,CL t �nc�J.�e-�1�.�r5 °�S o c� ^c-�j D G. ��...t..+v� �...t�.�..�®rt- 'fib�pn v—�3 o'F c„�--�,._,•t"r-r 2 ,,,,, . <br /> Work will commence on or about —20— for approximately <br /> PFrccna- 'rZT-oY�.,.-��w�co - <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 /> 15 _ <br /> Signature of Applic t-Title Date <br /> UB-SVWKI STERPSIENCROACHMENT PERMIT APPLICATION COC Iola) <br />