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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 0� <br /> OFFICES USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> Co Oe rTon EXP. DATE 65/01/0.205/0//O <br /> ATT / 2 VALID - (o" 7 TO 0 I © DRIVEWAYS <br /> (Applicant Name) STREET Wfilb, al' AVE <br /> AREA .STOCKToK\ QUAD 11AI <br /> 2,300E 8/yJ/LF Ad TYPE � <br /> (Mailing Address) FORMS _-AW4J <br /> NOTE <br /> (City, State, ;Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A 14 iTo10 Koi�FZZ <br /> �{C <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the SO V r# side -of <br /> WAV-0fAtJ approximately 160 FT feet/mile 111/0 _ <br /> of -T'hloQA/ToAJ Qdt- .by performing the <br /> following work (description of work) : <br /> Qrr ro OP4AI T2b .,Vq 591=' /-.? lqo-, , paeC 2-y° Ercj£E.c) T_'ccb <br /> Cafi;n-1 ai,4 AAnd Cc 6;,r1, Arr 7o PGA to fig"x yo 60.-k f 't PAZ) AD OUCC *"x 9I"X <3" <br /> CAV A115 r. ALL 00ke AOAla W1711/.y Roa. <br /> Work will commence on or about for approximately <br /> 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 /> /�k <br /> 7 <br /> /-//-off <br /> Signature o Applicant - -ri.tle Date <br /> MASTER.PS\FEESCHDL (6/00) <br />