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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3 Z22-'10(, <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB #_ q-(� REF # <br /> Department of Public Works APN CR # <br /> ` <br /> EXP. DATE ��/Solo <br /> Ac P-0 N blNN6L VALID iS� TO /U is olo <br /> (Applicant Name) DRIVEWAYS: <br /> STREET _�nf�E�S �D <br /> NA ST. AREA _T,44Gy I QUAD SGcI <br /> (Mailing Address) TYPEFORMS &,aV <br /> 'NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> rn N <br /> Z7 a D <br /> rn Z <br /> O � 0 7C7 <br /> >M <br /> tV C M, <br /> The undersigned hereby applies for permission to.excavate, cona•truct and/or <br /> otherwise encroach on-County Highway Right-of-We --on-the © . Ttt-.: -:.._ <br /> L�M M��S p_pptc� �' �_ - side.: #'.. . - <br /> approximately 15 feet/mile VEST ' <br /> of C�©1z1Z& a-10 _( W OA (7 VEST <br /> PLp�G� p� by -performing the <br /> following work (description of. work) : <br /> (�c►.l h l�' of Z =4" GDLtDU 1TS �0 xh0 SC�LtG�80X <br /> Work will commence on or about AFVJ G. <br /> days. for approximately <br /> I, the undersigned certify. that I am the owner of. the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> ins ection and approval. <br /> Situra o plicaat - Title / <br /> Date <br /> XXSM.pS\n=C=)L (6/00) <br />