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APPLICA71ON FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> DateOFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 j c»0 5- REF:a <br /> Department of Public Works APN CR 4 <br /> _ EXP.DATE <br /> �1t�R �13t1 y C f lett l}!4 SOcj gv Zen! VALID 11-0 y TO f 4=i _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> f AREA ��r,Yrc�c�vt QUAD ftt t I <br /> F 0 D x (a t TYPE <br /> (Mailing Address) FORMS <br /> NOTES i <br /> -f rkfy tCn1 (:h ri'S�aB I <br /> (City,State,Zip Cade) <br /> (Area Code-Telephone NurnWr) <br /> Sketch(Detailed plans may be submitted) <br /> r <br /> i <br /> ; <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 /> OT by performing the following work(description of work): <br /> %-E�m /,��11114D LL'sUk6 6.4 ��R1�fn�N ,t3tvd Gr�k 5� t C��a /�yE sFc ,v S�- <br /> llJbKiY�''f1f <br /> w�r�Pm � lc� Prn �critnt� to-ia-�� g�t� �trrr �=c� Pm <br /> Work will commence on or about_ l0 ti r-c?5 for approximately _ days. <br /> i, the undersigned,certify that 1 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 i Date <br /> =7OP SV.IWMA3fER.PKNCROACHVEN7PERMTAPPi.ICAPONL`OC (01138) <br />