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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (3C—F- 01 , 2010 OFFICE USE ONLY <br /> i <br /> To: San Joaquin County JOB# 220019 REF <br /> Department of Public Works APN CR <br /> EXP. DATE <br /> �-� VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA ct QUAD <br /> 333 C�W�'CUPT1v L A TYPE �— r' <br /> (Mailing A dress FORMS y5 <br /> CA Clro3l7 NOTES <br /> ` (City,State,Zip Code) <br /> VI - tP4"54 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> PLAJ.s' v_V%U,0sef) <br /> The undersigned hereby applies for permission to excavate, construct an !or of e ip�e croach on County Highway Right-of-Way on <br /> the 4rAyT side of 1TA� 5 _ �[e Ir'IDO feet/ iie <br /> of EL>iJ[14 5�, by performing the following work (description of ork): <br /> G_—ods �4 APID OVV tJgz: 51DUV)D LAME AIApIC-4 AN <br /> Work will commence on or about A for approximately 12-0 days. <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 /> Lo <br /> Signature of Applicant-Title Date <br /> -PUB SJ'WMAS11; APPL;C.Ii ION.UCC j0'.,091 <br />