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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date "`, �" OFFICE USE ONLY <br /> TO: San Joaquin County JOB # flQDS REF # <br /> Department of Public! Works APN CR # <br /> n <br /> EXP. DAT <br /> VALID S / TO Ul0. DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 7 AREA s;� UAD /«. <br /> G_.. A &N C Kj"�' TYPE A,1r& <br /> (Mailing Address) FORMS. � i <br /> y 2 NOTE <br /> (City, State, Zip Code) <br /> ?-'Cn <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> C U') <br /> J!A?D-M.7Ay—r&AF)-IC- 5 R1.c_C�E M�(AI�Tl/9)+1 � 1i2�NCa SIJ-We�►2�G fjGtt o Ts <br /> �trar2�,tXa Gc�i2ff/.t JL+ �dtz�S,� Ti..x�-Urr�Y ?/Zi9Ff�t cac�'y2dZ 5'W ,8� -{ cr, a <br /> - �-rit.+�rrr9 i�o wrrM v ruf- L,q,uE ofd•'N -A N a �PP�i�i K7E r���• � �: c�xa <br /> rn <br /> The undersigned hereby applies for permission to .excavate, construct and�r N <br /> otherwise-encroach on County Highway Right-of-Way-on-the side.-•of. <br /> TC mA1 k4 ry Wl`Ism approximately b feet/mile tv t;;—� ST <br /> of 9*-P*.+dt.. 0 4 STOLy-rc9a, 'C by -performing the <br /> following work (description of.work) : <br /> 14 e" o2-h C7 0 <br /> Work will commence on or'about. AL) f, Lao h for approximately <br /> 5 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 /> !tion and approval. a <br /> S ur icant Title Date <br /> MASTER. ® (6/00) <br /> .4 <br />