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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date duq&SI )L-9 OFFICE USE ONLY <br /> To: San Joaquin County JOB # //60S REF # <br /> Department of Public Works APN 25'v - 140 CR # D329G3 <br /> L EXP. DATE <br /> "/ c � i'If�Ll�'CJrI VALID ��,, p TO 9/a!�7 DRIVEWAYS: <br /> (Applicant Name) STREET YYC'ICIyydn A ev, <br /> AREA QUAD L.V <br /> TYPE <br /> (Mailing Address) FORMS Gucci ,e-29 <br /> NOTE <br /> (City, State, Zip Code) <br /> C-2 '(7171=-K,-) ?/ 649 - zi�3 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> pf gra <br /> S f L l- <br /> VA `7 <br /> CU <br /> The undersigned hereby applies for permission to excavate, cons r ct and/or <br /> otherwi e encroach on County Highway Right-of-Way on the or side of <br /> (,��� ✓� G, ., approximately 14a-) tee /mile <br /> of 7luyh-F'— �eGo� by performing the <br /> following wo k (description of work) C� Z )(2' SG"h'� d'' Cwcia7c <br /> work will commence on or about u � � for approximately <br /> 10 t yc 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 /> ins p on nd approval. <br /> G s z2— <br /> S ature of Applicant: - Title Date <br /> XASTER.PS\FEESCHDL (6/00) <br />