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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 07 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 11065 REF # _ <br /> Department of Public works APN CR # <br /> / <br /> EXP. DATE ✓� 113lo 7 <br /> �Y - Ddu O d4 - a OC/e& VALID T'� TO ��i.�o7 DRIVEWAYS: <br /> (Applicant Name) STREETSr.l yzmen-ko 131ud, <br /> AREA urnlon QUAD Al W <br /> TYPE Tt°rr+�7, 2d. CIOSUrt <br /> (Mailing Address) FORMS 55 /UjW <br /> NOTE <br /> /horn l-on Cal 95L61. <br /> �2 (City, State, Zip Code) <br /> �20q) 79S /0 9!0 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Sce V1C's W;t, MaP <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> SZ.t✓G.s�eh�o /ud. approximately lseA-Ieen feet- mt e 121n-e. cSf. <br /> Ala cu /4oDe Rd. by performing the <br /> following work (description of work) : P-kgurc oi .�aC k�en{o <br /> B/uo! in 1 e Town 0or"n M ' " O - <br /> Work will commence on or about _ .511—/3� for approximately <br /> 2 hours elfty5. <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 /> -,�/? - e - 6r04 <br /> Signatu of Applicant; - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />