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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date t l—)Lo—() OFFICE USE ONLY <br /> To: San Joaquin County JOB# /l01 REF# <br /> Department of Public Works APN CR# <br /> _ ' 1 EXP.DATE � <br /> r CAY LAh ;1 ch 6r) VALID2te <br /> 0 / DRIVEWAYS: <br /> �7 <br /> (Applicant Name) STREETAREA QUAD 111E <br /> t I J S G. LAD G)C.•ePU\,-Cl �� TYPE � <br /> (Mailing Address) FORMSwT, X25' <br /> CA xSZ v NOTES <br /> (City,State,Zip Code) <br /> 20q-0131 -��l3g <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> <� 0,-�cYIed <br /> The.undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High ight-of-Way on <br /> sef GcrOss Co11ver 9-taad approximately �� ee <br /> of - LSA/ 1P•P• by performing the following wor escription of work): <br /> 1ao v - PC) a-c-, acro-ss Cok he"- (Loci Cl `�" PVC C CMU-1-- <br /> Work will commence on or about q <br /> 5n as rCCewT_�for approximately 1 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' accord nce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> /,, 11 1u/t) <br /> a70Ae of Applicant-Title Date <br /> EAPUB-SVMKIMAST SIENMENTPERUTAPPLICATIONA0C (01108) <br />