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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date ~tl/(,/I(.. <br />To:San Joaquin County <br />Department of Public Works <br />((,..e; <br />(Applicant Name) <br />4rJ-1D WtJ+LN <br />(Mailing Address) <br />~bM.Q.~qSLo"f <br />(City,State,Zip Code) <br />l.IOIr'Yc..-17"7 <br />(Area Code.Telephone Number) <br />OFFICE USE ONLY <br />JOB#7 Jt2t2£~REF# <br />APN CR# <br />EXP.DATE 6-1 $-/6 <br />VALID ~-&1(;TO 6 -/>-16 DRIVEWAYS:STREET Crtq;rl L,b f /2&1 • <br />AREA -r;-g if QUAD <;W • <br />TYPE B e-tL'h!7le • <br />FORMS s.;wtV £29 <br />NOTES <br />. <br />Sketch (Detailed plans may be submitted) <br />,, <br />The undersigned hereby applies for permission to excavate,cons(ruct and/or otherwise encroach on County Highway Right-of-Way on <br />the 'S.llC.:k..side of GM.¥+I iYl<approximately t.l Q ~mile t...:!rJJ <br />of ~~(J ,l.e.1 'by performing the following work (description of work):Ii>1Ms.h1\'l.-)L II-:>A.,....I" <br />Work will commence on or about Oz,.~for approximately days. <br />/.~ <br />ture of Applicant -Title <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 />E:II'Us.sV.WKlMASTER.PS\ENCROACliMENT PERMrT APPLICATlON.DOC (OlIDBJ