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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12-6 -2010 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> PG EXP.DATE 7 <br /> lT VALID 3 Tb DRIVEWAYS: <br /> (Applicant Name) STREET 6IeoNr Y.z6 PU) <br /> AREA QUAD <br /> HIM M 'ARK F1. FAST TYPE <br /> (Mailing Address) FORMS Ss ww <br /> F-RESN6, CA 93720 NOTES <br /> (City,State, Zip Code) <br /> (557) 347-5246 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) RO ED-7!`rte <br /> EE-E A-PACMEQ? XeRHES <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the '�4.,7W side of I&Arr A4146 ie , approximately /06, feet/mile �AS� <br /> Of- wE 5 rgc,_,,q�,p ,r?P :A_ /P_' by performing the following work(description of work): <br /> ROUTINE REPAIR f RffL4( 14UJT OF QVERRM f UAIURGROIJAID fLEC7PJC <br /> EQUIPMENT 6N EX15TIMIG AOCIS AIX IN EXISTIWG A UCLOSURES AT L0WD1lL� vA2rac�'S <br /> Work will commence on or about_ f2- /;-Z/&l for approximately 9D 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 /> 00e, X_'_ - a -4a-2,0/0 <br /> Signature of Applica4O Title Date <br /> EIPU6-SVWMMASTERPSIENCROACHMENTPERMITAPPLICATION.DOC (01MJ8) <br />