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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date _ JOB # REF# <br /> APN - - CRV# <br /> To: San Joaquin County Highway Department. EXP. DATE ,-IS ell <br /> VALID S- - TO DRIVEWAYS: <br /> AhyANCED GEOENVl2ONMENTAL.?JVC. <br /> STREETXi/K <br /> (Applicant Name) AREA QUAD (I a-_ # <br /> e63-I SHAW ZoAD ,e <br /> FOR-NIS <br /> (Mailing Address) NOTE <br /> sror-KTON , CA 95215 <br /> z. <br /> (City, State Zip Code) <br /> (20°► 1-4(, - 10GG <br /> ,. <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> pLEAS� `�-E- A��AG4-#�1 \rJv`:2K ALAN I)AT f--) 1S .7Ai�Q9�f�Y 2(JC 1 <br /> rrr-' <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County <br /> N.i=hway Right-of-Way on the N o -r H side of t=Lr-\w Gc)b ,a.y E Nu E_ approximately <br /> ►yo- i GZ1 mile ,pyoT'i-h of 2123 c:.�,�rr�Y LwLva. C7CkTGN ,by performing the <br /> following work: (description of work): T Ns FAL A Tr r,ay r_. 2_ - —N c H t,`�1 C S T R E►� <br /> tee, ANf7v ANS ML1- �a Cce�E�►y�-ilETwEEN �c� aiv(� ` tom FT. ) <br /> Work will commence on or about Ac V,-T L 2 ti,-1 ?001 for approximately 3U days. <br /> I the undersigned certify that I am the owner of the respective property, or am qualified to represent the owner and <br /> agree to do the work descnbed above in accordance with the rules, regulations of San Joaquin County and subject <br /> to inspection and approval. <br /> S7AFE 5 rFN= S i 2 ,3 <br /> _ <br /> SIGN1 ATURE OFF APPPLIC,,%NT - TITLE DATE <br /> Sr <br />