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y <br /> APPLICATION FOR ENCROACHMENT PCSRUT <br /> PLEASE PRINT: <br /> Date /0-27 2 D 1 S OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# _ <br /> Department of Public Works APN CREXP.DATE <br /> _ <br /> (36-4j6 ��'�^ //.Z.Z��3 VALID <br /> l- -�Gf,�`TO 3-/S---ZG�/G, DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA �,� QUAD <br /> TYPE G �? <br /> (Mailing Address) FORMS Q <br /> _ NOTES <br /> Arq.S 2 O L� <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Re <br /> /� <br /> 'B�l o7-a IQoQ <br /> Yea°iDlA e� IS�Op t� , 1C <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way�n <br /> the W side of rE approximately d.L/ fee i e /►� <br /> of_�s�,N P 2e� L r� pn ,by performing the following work(description of work): <br /> 0 1 p ,." *LVW �o e <br /> Work will commence on or about 1! 2— 14^ for approximately / a O 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 /> 6110ENTRALSERVICESICLERICAL1Pu&SV.WKLMSTER.PSIe4CROACHN,EWTPERV,,RAPPLICATIONDOC(0.113) <br />