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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date I1 10 09 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7300214 REF # <br /> Department of Public Works APN CR # <br /> ((��� ��jj EXP. DATE IZ•tj•t <br /> O LAPW e. WAN lA� VALID TO 6L!Z .c78 DRIVEWAYS: <br /> (Applicant Name) STREET J4#,0&Z5 Z.C'1973oor <br /> n AREA-JtdeS/ QU l / <br /> �3(�C7 tE7tt r Mlle ('G 4J TYPE /N <br /> (Mailing Address) FORMS <br /> 5ra(kp AjC <br /> , A . gsu r. NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 5EE ATTACOVD PAAWW6'5 of (3) 5(TES <br /> E <br /> The undersigned hereby applies for permission to excavate,- construct and/or <br /> - otherwise encroach on County Highway Right-of-Way on theF� I?WtSS side of <br /> of approximately feet/mile <br /> 77 <br /> following work (description of work) : t,Fjr by performing the <br /> £d 6 fJ'FA,)7-,Y 5'T. it rok'19_V=,pV AW. <br /> Work will commence on or about 1.tW Zoo? for approximately <br /> 1 <br /> 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 /> to -oe <br /> Signature of Applic t - Title Date <br /> MASTER.PS\PEESCEDL (6100) <br />