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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I l) I q - C OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> REF# <br /> Department of Public Works APN CR# <br /> _ EXP. DATE — t t 6 <br /> �-1 A C�� � A, VALID p TO t �y' DRIVEWAYS: <br /> (Applicant Name) I STREET Sr. A, <br /> I AREA a(c,+ QUAD 96 <br /> aV YV t�[7ClC6 _ TYPE ?nc�a-�� UCt� P►Q�S Hyl f )�rcy, <br /> (Mailing Address) FORMS u,, 1--zR <br /> - NOTES <br /> 1 11 ,Y, co1� (ai � ii �� Amu. 0 751uh� ! <br /> (City, State,Zip Code) "'v <br /> Z- AIM <br /> (Area Code-Telephone Number) <br /> SketchDetaile ns may be submitted ow <br /> 5 �c <br /> 60- �\ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the h.54 -/ A01e �{ side of 5Zy ,le&ke AVe approximately -2Oo` mile <br /> of 1-'I" (*E.. a,���/9% "D E by performing the following work(description of work): <br /> A5 c�i v�F? C �12G —Ltia // C iz.a c�� t; 'p f/ i tv _7 Sc=Z�014 7, <br /> lfQ r✓'rf� 7,t,2z yc1U�' yQ <br /> Work will commence on or about As Mti,j-- ApvrUvE e for approximately J d4 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 v i a ordance with the rules and regulations of San Joaquin County and subject to inspection and approval <br /> ig ture of ApIlicant-Title Date <br /> Y'FOR1A5L TPAPLATES£!,CROACKIENT PERIAITAPPLICATIONd.C1081 Ej <br />