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2095781974 M St.,Modesto Ca 09:44:49 a.m, 05-13-2008 2/3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date ___ -13-01 OFFICE USE ONLY <br /> To: San Joaquin County JOB #_ 071 /7 REF # <br /> Department of Public Works APN CR # <br /> IEXP. DATE <br /> VALID D O lS�DB DRIVEWAYS <br /> (Applicant Name) STREET <br /> ��' AREA�. ICe Q» <br /> TYPE 1z <br /> (Mailing Address) FORMS - <br /> l/fi1n /1 �5-36V NOTE <br /> (City, State, Zip Code) <br /> oy � O <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate; construcj `and/ar <br /> ot:$erwi encro ch o Count Il'ghway--Right-of-Way on the K �C•;;A. ,t la <br /> aside -of <br /> pproximately ee mile <br /> of N (#'J <br /> ,following work <br /> (desc iption of work) b perform'ng he <br /> m o , R� <br /> -n v -� Tr' <br /> Work gill commence on or about `'J -tLp -O <br /> days. for approximately <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> `�/ l�l�'YU tom`✓�Gt.�° ��l L� <br /> 3 <br /> S at of Applicant - itle ` <br /> Date <br /> MAST$R.PS\FR CHDL (6/00) <br />