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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ik 2 .- 2 , OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> ! C ��`t'i o�C-% VALID i TO - L.w i DRIVEWAYS: <br /> (Applicant Name) STREET <br /> -61,WL MA- <br /> AREA Ir&L41 <br /> / QUAD <br /> C °X J c1c, TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> —� (City,State,Zip Code) <br /> 0 1 ._ % y_ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 7-)2-4 d a-S b.j)L L. P--- v 1 N 6 f-"i�pa.� +7; oci /{p-A r i L 1. <br /> 7Wek' k,.AIt.L )o I�A YJ f' A i3r car aNc� <br /> G v�itY IC1 - 1Sr +N, C R4om <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the I �,v' ^side of J) 12 approximately 'c�� dOmile <br /> of t . C,-4,- by performing the following work(description of work): <br /> �1e'�L- in. !h�-. •Vii['-` y'v1 C' �,'/fes'C �1 it 'T ="iC'C-•i� ' r`�1..' ��-'X � �1i''�'r'1 c'�tL <br /> Ssir=" cf.� —iit =i Si Srr>F r, = t'SIZt� iz > `� ;�' S, Ca� J <br /> S 1?`<> >" Jam: 4� f e �M I �i�%C—� �'•i= i'S i 1t i`� �"^�l� !,�'c� v,.'r ti i, {� <br /> die<'? t: r.- r j� r� 'c= C�n i? IZC"-\ <br /> Work will commence on or about 12-- 28 t for approximately 9C 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 /> Si Applicant-Title Date <br /> f, <br /> E:1PUB-SVWKIMASTER.PSIENCROACNMENT PERMIT APPLICATION.DOC (0106) <br />