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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7T✓03'--6' REF # <br /> Department of Public Works APN CR' # <br /> _ <br /> EXP. DATE /0/" d, <br /> VALID lP O TO /O Oho DRIVEWAYS <br /> � O <br /> (Applicant STREET <br /> AREA ST.C!ri/ QUAD S�rt <br /> TYPE _ <br /> v (Mailing Address) FORMS <br /> Sr CIL 7 A f (f14 /S�� NOTE <br /> (City, State, Zip Code) <br /> X091 `Iy,2 /ln5- 222 1'19 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Rwpn,,,er .5F,ge 77D EP-06-/8?-SS <br /> /y�9l1f7TAl.V 7A2r9F0=1G Coil/TieoL� AAl A0,09P C'lOS&45 .91,Go6VEv, <br /> The undersigned hereby applies for permission to excavate,, construct and/or <br /> otherwise encroach on County Highway Right-of-Way -a +-r- f9C2DSS �!; -1 f <br /> ,5446 7' approximately 23D feet/tee <br /> of /2I1C9 EL a�TREE1� rDCkr Al , by performing the <br /> following work (description of work) : <br /> M 251 <br /> Fi9c/�/TiF T2F(/eiy D_ .tl G BESTS!/�E �F "6 ST 2257_ M <br /> T/ THLIrIZAS AleE 7,0 ,e&4 0K T141-25s <br /> Work will commence on or about !s-1.2 -Olo for approximately <br /> 90 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 /> Signature of App ant - Title Da <br /> RETURN PERMITS TO. to <br /> MASTER.PS\FRES®L (6/00) �G <br /> JOB PROCE89MG DESK- BLD 1 <br /> 4040~L,WO <br /> BTCA 9=04 <br />