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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 2/ J� OFFICE USE ONLY <br /> To: San Joaquin County JOB # ir� REF #_ <br /> Department of Public Works APN CR #_ <br /> EXP. DATE 15-oE, <br /> �TT ' " I �tiIPJ VALID �J'�-c ra TO 6-15-0' DRIVEWAYS: <br /> (Applicant Name) STREET ���K <br /> AREA `yTlt 0 QUAD L✓ <br /> TYPE i C4.1 3(' <br /> (Mailing Address) FORMS t X'-09 <br /> J / ^ NOTE <br /> (City, State, Zip Code) <br /> 2.v V t y <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Q F7, �7 <br /> rr a � fl�r�i'15�v <br /> IK 04y <br /> b,,,s4 ' S��a ��VuU <br /> p% rc V) � <br /> 2 t41- <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the _A/.` 5 side -of <br /> jw/k 0' ' approximately 7© ee /mile �aY� <br /> of 7 by performing the <br /> following work (descript:ion of work) : Ayr fru . <br /> � : 4T7' <br /> / rr lv �FGoes /FcFi �wrAiirof/.� <br /> Con1J,i ,w �„�. f�7 fo frnGti App/.x ;5-fT 71" isi p/r/<e1 j y"Cc la Gl /fir;n r7U �// -�/s�urcd 1 I,KP <br /> or jrj/,/' rr! t- rae'_. re- 1'�'c� n Yi /1'�U l✓2t�. Ali U cf k- ��' C.0.'n� tf77� �r C✓. Vv6 •✓Je'f4,5 - <br /> Work will commence on or about /�Gr�� 2. l�t�s for approximately <br /> 70 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 rulers, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signa re of Applicant Title Date <br /> MASTER.PS\FEESCML (6/00) <br />