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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date !L OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7.3079- 3 REF # <br /> Department of Public Works APN Cy # <br /> EXP. DATE -/S-O& <br /> 0 7Y Wc.�ro N VALID 5o 0 TO f-15'-6G DRIVEWAYS: <br /> (Applicant Name) STREET L oOMIS eV. <br /> AREA STaclmuv QUAD <br /> L300 t' �TLNy1�1 L / TYPE s ly�i 'e-og <br /> (Mailing Address) FORMS —, EdJCh1V4 <br /> / NOTE <br /> SVocklon. C4 95-210 " �60I <br /> (City, State, Zip Code) <br /> 204 LIPI 439�1 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) r� <br /> 'b o A <br /> - In <br /> D rn <br /> 00 <br /> z m <br /> A77' clow`. 0 0 <br /> � N �C7 <br /> 30 no Z <br /> A 00 � <br /> ul <br /> The undersigned hereby applies for permission to excavate; -Son truct and/or <br /> - otherwise encroach on County Highway Right-of-Wav on the ryt 'ed9Af9side -of <br /> 100W' Ra.e X4 99 AgAlhe , ZO. approximately Z5 ee /mile Orr' <br /> of rllt Col2N617- by performing the <br /> following work (description of work) : <br /> ON-Al CoT AND 7XCA10 faiz PK&C-14&ir OF 2--4" N.45-tle CoeJeu/Tf: <br /> W iJILL W folWiA er Ex'IsrlA1,6 u i6,D CABLES, <br /> Work will commence on or abou "045� for approximately <br /> tea® days <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> ElGlA(K&'C' �60 <br /> Sig:'P.t�.E.SCHDL <br /> aa of Applicant - Title Da et <br /> MASTS (6/00) <br />