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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICEUSEONLY <br />L I IV De"""lJ /CA i S :;l-~<.. <br />(City,State,Zip Code) <br />To:San Joaquin County JOB #/I~REF# <br />Department of Public Works APN CR #EXP.DATE ---------~--jl2I---~~-- <br />L/A/O£lrfffr-ns ~l.f.41Mt$1.df..~w\.11\.~VALID i2h'/t~T6 'o/P/Lh <br />(Applicant Name)STREET ~__'..';eo=_~N-r~~%~._ <br />AREA WP6A/QUAD ,,4••'16~_..1'.0.11(.1)<557 TYPE 72M/.b;4P ~..e6 <br />(Mailing Address)FORMS ---------------NOTES <br />?-o e;-l(8 2.-6>'f '3I if,,:.~d ..-....' <br />(Area Code.Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />DRIVEWAYS:• <br />kVI. <br />JJ <br />~ <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the M"z,-n+side of -;:124"'7 s ,.approximately feeUmile _ <br />of ..__,by performing the following work (description of work): <br />C U9$VlU;dF FI2.8AJr ST.(J,t::-,w-.,;e.I 1'l44/(!1<c"1'Sr>-D'V nfo='IOI4sr,AIuf.) <br />7Juwc.AN /2.",0...,7Y£W,,"?T 1'tL"W'l 9:~oA+l"-to.'>""'"VVI ' <br />Work will commence on or about M.4-Y ;)..//20 I (,.,r I for approximately t>AJ~(I)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 />~~r:;2£5)&+eo Mew~Signature of Applic t.Title <br />Y:\FORMS &TEMPLATESIENCROACKMENT PERMIT APPLICATION<bo l08lO8) <br />'i-8-/<" <br />Date