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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date (It//''//''- <br />To:San Joaquin County <br />Department of Public Works <br />(&(5 <br />(Applicant Name) <br />4cJ-/o W~-I:LN <br />(Mailing Address) <br />~bM Q.li+qSLo<{ <br />(City,State,Zip Code) <br />C/Oit'-ZX (,..•t7"7 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB#Z3tt2.>2.REF# <br />APN CR# <br />EXP.DATE fr{>-!6VALID?-/Nt:.TO 6-/$-/6 DRIVEWAYS:STREET CJ l,tWI (?(• <br />AREA C/g""mi-s QUAD NG • <br />TYPE '!I~• <br />FORMS &:29'NOTES <br />The und~rsigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ~••~side of £.141""""\d .approximately ..,D <@Wmile ,cC,L <br />of A\f4.-k.t<••W\<S.},c:.\~U'!>H ,by performing the following work (description of work): <br />TI:>:C"''>\J;.'\7 -?t It->~•••••.Io on Goo,A,("';14 <br />Work will commence on or about Ol.!1 for approximately 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 describe ve i ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />Cfl./!ro/I bDate <br />E:lPUIl-SV.WKWASl'ERPSIENCROACHMENT PElWlT APPLICATION.DOC IOMl8)