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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ - I C� - O g OFFICE USE ONLY <br /> To: San Joaquin County JOB# !t 0*05- REF# <br /> Department of Public Works APN CR# 1 <br /> EXP. DATE — 115.09 — - -- - <br /> �• VALID ¢2•IS,oS TO /• y. -- DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA AyAgMCCA QUAD _ <br /> —1 [0 rr. Hl -H 1s1AY 120 TYPE <br /> (Mailing Address) i FORMS AZq <br /> NOTES --- ---- ---- j <br /> meq_ 533t� <br /> (City, Sta �Zip, ode) I- - --- --- <br /> (Area Code-Telephone Number) �— <br /> ---- ---- —__—I <br /> - ------------------------ <br /> Sketch (Detailed plans may be submitted)56e P,,%,x <br /> ` � I <br /> o <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the E/W side of_v w to o gv Ay approximately ( feet kl!yR i H <br /> Of IL-Al- W Qc,P MC. ; by performing the following work(description of work): <br /> ___ R��P t►.t Gouty?`f � �• •� _ - --- <br /> Work will commence on or about AAiD Dgr -MM& ?.oe9 for approximately 14 T Y <br /> da s. <br /> I, the undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ---PrIVoV, (o Zoo$ <br /> Signature of Applicant-Title Date <br /> E.IPUBSV.'WMASTER PS�ENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />