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1 <br />Y- <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PANT: <br />Date <br />OFFICE USE ONLY <br />To: San Joaquin County JOB# <br />Department of Public Works REF# <br />Cs,< PNC:Js,r XP.DATE <br />VALID j7 t" TO !t i 15'" DRIVEWAYS:Applicant Name) STREET :i;!# <br />AREA '" ' QUAD ? <br />TYPE D- *e111114%Mailing Address) FORMS r l:s <br />NOTES <br />City,State,Zip Code) <br />Brea Cede a Telephone Number) <br />Sketch(Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-o"the side of tY 9 y Way onofapproximatelyfeet/mile <br />by performing the following work(description of work):N <br />f 'k"..'a'l.J •"II.ST/c'-t,"r>dt 4 !fit' ';/ r r'1/y` — <br />Work will commence on or aboufi S --- 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 theworkdescribedaboveinaccordancewiththerulesandregulationsofSanJoaquinCountyandsubjecttoinspectionandapproval. <br />Signaftire of Appl1cant v Title <br />Date <br />P-79CEMR/i.gL gCESG£r2ICAUPLI2SV.4VKy,J:ST'cRFSLiJCROACH;1EfJiPEFJ.!qAPPL1CA77011000 pli3)