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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5-L-5-1 a-7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # /IddS REF # <br /> Department of Public Works APN CR' # <br /> (M(Ck4,g9L EXP. DATE <br /> ro I ME79-0 Ar-(6Z 714A ,Sm 9sidr- Sfiw-L/Lr=rpt c. VALID 7-A117 TO DRIVEWAYS: <br /> (Applicant Name) STREET firms * <br /> AREA SMc,11r-rTd nJ QUAD i0JS <br /> ?7ZN4pt,r,, STe 5/yi 5AG7 LAKa CI rye�J-1 TYPE <br /> (Mailing Address) FORMS, 25' <br /> NOTE <br /> (City, State, Zip Code) <br /> ($DO) '755- 4Sia 4 3 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans ma be submitted) <br /> M i 0D- G&P-65 <br /> CJ'1 <br /> - X <br /> N <br /> \t3 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the N eVL.,r+ side of <br /> l6wO;N6 Ayr,. approximately -7 i:7 feet mile <br /> of by performing the <br /> following work (description of work) : ntw< �7tQ� - 1iatcr CI) Z" 1+10(tC. (anlvJvl'( <br /> i-o^- ^Ty-li- PJHIosc aE-- J: r(f ,t c)pTic- Cpq-,,L.4-- <br /> Work w' ll commence on or about Uu. j I �60 1 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 /> rdV,- AA C 5 Z d --7 <br /> S gnat r of Applicant - Title Date <br /> MASTER.PS\FEESCIDL (6/00) <br />