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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date -ar-o? OFFICE USE ONLY <br /> To: San Joaquin County JOB # ?30 -?-5 REF # <br /> Department of Public Works APN CR" # <br /> A �' C� Ty I.�t,ft�on OSPE <br /> EXP. DATE <br /> T <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET VALEAICJA <br /> Z3Do E E/GNi tt/c j2 AREA .J704JrAe QUAD LV <br /> TYPE 6MQ9-DAG;iFAV_"T <br /> (Mailing Address) . FORMS St$ <br /> I NOTE <br /> $foGkl�orl� CA 952/0 <br /> (City, State, Zip Code) <br /> Zo9 y�� -y�6� - • <br /> ,(Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A�f obs I/ <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County. Highway Right-of-Way on the li/EsT side -of <br /> VAGtNC/,4 approximately Zoo Fr feet/mile /VOKr# <br /> of KAHM�,� Lqd�' ,byperforming the <br /> following work (description of work) : Arr iv <'LEAR �E ,Q hD pi. et 6Fr"X �b <br /> Cc)VegcT4- ND A"D TfLeo e4&A4T7. 477' To P/Ace' eVA101117' F9ort t"bl L' iv <br /> CAdlAMI AAID C6 AJ DVX-r%' ro Exis'r/.'6 iPG cv ,sou 4.tlo c,GBi-vt 1 AS S/1�� <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 /> Signature o Applicant - Title Date <br /> MASTER.PS\FEES®L (6/00) <br />