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APPLICATION FOR ENCROACHMENT PERMIT E1 r_n <br /> PLEASE PRINT: JUN AM I I: <br /> na <br /> V V 1� OFFICEy)7EF4.QIfLY. <br /> Date // �. �Ul i; wokK s <br /> To: San #�Joaquin County JOB 052-40 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE /"04G <br /> T VALID 1-_4 <br /> J-0GTO DRIVEWAYS <br /> (Applicant Name) STREET 41M9;5f1 3� <br /> AREA �srjeA/ QUAD <br /> GO `7 V kt, _St_e_gA , TYPE �G DEQ <br /> (Mailing Address) FORMS 4Z9 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> r " 4„ o PIA” -�i Ni4Il 56- 45 F6tz <br /> CA�.r VVI �,t-j-� C' 1 Fri f^"A A 5� p P l�e�e �- <br /> 5wee <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the -ya-l'1�_ side of <br /> approximately 13 S, � feet/mile -/ D <br /> of .1 Le,9•�/`�i4� by performing the <br /> following work (description of work) : - <br /> X C dCleI-71--P <br /> Work�+will commence on or about for approximately <br /> G7 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 /> o <br /> 1- Titla Date <br /> Sigriature of n'rP 1 �� - RETURN PERMITS TO: <br /> abs A?�.tsy �+ pe" <br /> MASTER.PS",,FEESCHDL (6/00) YVr • •■OC I SI\-Iw 1 <br /> *X0 Vftw IW <br /> STOC , CA <br />