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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Q � � �p Q, <br /> OF2FICE USE ONLY <br /> To: San Joaquin County [APN <br /> B # 73�7�r'? <br /> Department of Public WorksREF # <br /> �J G. <br /> / R��ND G GQi�t'�A� l AltT� P. DATE �•t --b <br /> VALID 9�r •a'�i TOQ.1!5%j DRIVEWAYS: <br /> (Applicant Name) STREET <br /> r <br /> Z.'3OO E. ARE <br /> E 1&HT N( e. 1Q) TYPE QUAD _ <br /> (mailing Address) FORMS <br /> 5 roa(TON LA • H62 10 NOTE <br /> (City, State, Zip Code) <br /> Z,09- 474- 4675" <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 5 ATTR"ED l)Ute-. <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the E19F_G�i <br /> 6. 1 - <br /> of ( A .r.ry approximately ZDV feet/.awe side of <br /> following work (description of work) : , by performing the <br /> 112T T7) 01-ACP t() <br /> Work will commence on or about 41 08 <br /> for approximately <br /> 7 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 /> signature VL APplilaA - Title <br /> X08 <br /> Date <br /> MAS-.ER.PS\FEESCE L (6100) <br />