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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 D C.-0 �?- oO OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 t0005- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ( t•OQ <br /> l r,.,c VALID 10. 21. TO i .D DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> `EL-. 0 A TYPEdT pL'E <br /> (Mailing Address) FORMS IVA) A ZI7 <br /> n <br /> NOTES <br /> ( q <br /> (City,State,Zip Code) a <br /> �:2, .,1 a <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) 56�-1'sA-c r4 ,. s mac_ i =' <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the_A.) i2 7- 0 side of ; 4 CL?J�j%J`7_ 2 20P-L approximately 7 0,0 f mile_ ',,J'�. <br /> ofLSA,2 s 90 s', R-C)F,-C; by performing the following work(description of work): <br /> p <br /> 7 O-T-}U b! E T t IRJ C 1 1 K T�_tom- ! i ) A <br /> Work will commence on or about !o _Q� for approximately days. <br /> I, the undersigned,certify that I am the own er of the respective property,or am qu alified 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 ApplicantL T' le Date <br /> E PUS SV.WKWASTERPSIENCROACH%NT PFRMT APRi.ICATION r:OC (01W) <br />