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APPLICATION FOR ENCROACHMENT PERMIT <br />OFFICE USE ONLY <br />JOB#2712O~2-REF# <br />APN CR# <br />EXP.DATE 6-fS-{G <br />VALID 3-J{-/6 TO 6-(5-/6 DRIVEWAYS: <br />STREET l-ai"1"P !/A e • <br />AREA ~;e;,=QUAD <br />JU/• <br />TYPE • <br />FORMS 5'ff!R.)'f <br />NOTES <br />To:San Joaquin County <br />Department of Public Works <br />PLEASE PRINT: <br />Date ('A/I!'//f. <br />(Applicant Name) <br />4cJ.4o IN,,+-LtV <br />(Mailing Address) <br />~\:tM.Qy\-qs Lo"I <br />(City.State,Zip Code) <br />qo~-'Xc,-11"7 <br />(Area Code.Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />) <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right.of.Way on <br />the So~side of {.Qw":,,,c approximately 41:0 @'mile 4&11, <br />of S.Pt1,t (iA.vHo,......'""'<>"1 'by performing the following work (description of work): <br />10 TIAl>\o.\\1.-~l.Ib 6>.""oJt..)""'"G..J M&.i....i.."4 l.fJ('-/b.el{(".,h <br />Work will commence on or about ~O~t.••/~,J..;~~..•Z,-<IO-'~for approximatelyrJ 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 ve i ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />Cfl/IroI!bDate <br />E:IPUB.$VWKlMASTER.PSIENCROACHMENT PERMIT APPLICATKlN.DOC (011OB)