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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date q,— ` y O� _ OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> • <br /> EXP. DATE d� <br /> vANCF D Gf 0 Et,vonMFn4A VALID 4'2 A TO W b'-c-S DRIVEWAYS: <br /> (Applicant Name) STREET <br /> e AREA�•4,6wrZ QUAD �_ <br /> 837 SIM W �OrT D TYPE 6�G '✓ <br /> •r�.� (Mailing Address) FORMS <br /> S 1 TU BI cj� 9 S';?1K' NOTE <br /> (City, State, Zip Code) <br /> z�q qb 7 — 100) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> P6W / -4n <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on-the SOV T14 side_of <br /> coh+t(r AVtrwr- ap roximately -75 feet mile EASi- <br /> by "performing the <br /> of iA�'t�SfC�-tO/� of T"1Eo!•N16N !AQ AA/I� CAIr�.. A.-A. , <br /> following work (description of work) : A OVO4,)A WE?) bw-6 hy OVpr P/1M <br /> -ft�L ;Ayf% Arv4 40-AVIM Q►1 wfd S vDen %to-Lig <br /> T <br /> Work will commence on or about 1900 ft . to s& for approximately <br /> VL 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 /> • _ �Ro•�,�r NIA��,r oN-- 1g_ �� <br /> Signatu of(Applicant - Title Date <br /> MASTER.PS FEES CRDL (6/00) <br />