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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date to 1511.5 OFFICEUSE ONLY <br />To: San Joaquin County JOB# J< Z REF# <br />Department of Public Works APN CR# <br />EXP.DATE - 6-15 -16 <br />Nom! &014--e S QG c G VALID TO C (S - DRIVEWAYS: <br />Applicant Name) STREET e 115 <br />pp AREA t QUAD <br />D C5'5 II TYPE LC <br />Mailing Address) FORMS S 1/jj Gf <br />NOTES <br />City,State,Zip Code) <br />416- 740 - 1`752 <br />Area Code-Telephone Number) <br />Sketch(Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way ontheGSYsideof1, e l I S Lv approximately e mile <br />ofLv% by performing the following work(description of work): <br />PB 1-G. rn D-ts.Cr r <br />Work will commence on or about Z t 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 described a0e in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />S <br />Signature of Applicant-Title Date <br />EAPUB-SVWKIMASTER PSIENCROACHMENT PERMITAPPLICATIONDOC (01108)