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APPLICA TlOl\!FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date ~-2 7-\(p <br />To:San Joaquin County <br />Department of Public Works <br />'T'iS ~Co",s~:rIA.C\-I"'V\ <br />(Applicant Name) <br />l c -z •••\Vl "'or c "'"~_~","_",_'_~_ <br />(Mailing Address) <br />Cec£s ..__.~__q r;""5 o~L ''_.__. <br />(City,State,Zip Code) <br />b1-S7~-87(.,t/C:dl 20'1-(,7,5'-279 '1 <br />(Area cJcte:Telephone Number) <br />OFFICE USE ONLY <br />JOB#((oed;;REF #APN CR#EXP.DATE 1-15 /6 <br />VALID $-2-l,{TO ?-(?-g DRIVEWAYS:STREET ~~/W'U1f *.AREA IVW *G(h UADTYPEg/fPf!!12-Z q *FORMS <br />NOTES <br />-....--~- <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate,construct and/or othelWise encroach on County Highway Right-of-Way on <br />the Sa",!'h sideof'Tnolu1A'4 .approximately lu 'feetlmile __'-:- <br />of _i)'"U me..;;(l cA..~perfom1ing the foI/owing work (description ofworf():by,oose .c'-..~e\e \.La.r .e,<,,'•....s... <br />days.for approximately <br />Wont will commence on or about <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 ihe. <br />work described ove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br />M:IcENlRAlSERVlCES\Cl..fRlCALlPUa..sv.WKIMASTEltPS\8"tCROACHMEUT PER&~TAPPl.JCATION.OOC (iW13)