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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date r - S ' r�o 1 1 OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 13601 5"IV.-) REF # <br /> Department of Public Works APN CR # <br /> _ <br /> EXP. DATE �!tm"i' <br /> O Lk <br /> + 1 VALID Z�-�tL•(-!3�La t1 DRIVEWAYS: <br /> (Applicant Name) STREET �.� �, <br /> AREA QUAD AIS <br /> A- <br /> 33�o c . t�yHT , 1� � (Z1� • TYPE <br /> (Mailing Address) FORMSjwto <br /> S" 0 C kL� , NOTE <br /> (City, State, Zip Code) <br /> 4-Ca , -14 - til , y <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> - otherwise encroach on County highway Right-of-Way on the SO-NTA side of <br /> A L�Co �2'b• approximately 4140 feet/ala .AST' 2 i B' <br /> OTA t u p SQONCIWhy (-W.�S�iG�t. , by performing the <br /> following work (description of work) : C�{l.E, + QLALE 9-4" CPC. f t,oc^ ^14 oty GIS of <br /> W Ftp-1Wc ►22i. e�-1'EAIAiNG_ AW EA,,T �n1 Zlk(L 49ioQ-4 Vt;1L7tlL SAO t s A. l A*l+1 �r��3}�_ <br /> a.1 lit WIS of $CL�ap��� t�J; Cs�,iw1G- STYLt�iF- sZ�seR- nom . rcv4T� S 3c� <br /> P ►T S I-o;A C . 7\A k S c;trk IS Fort.. N "J NYU 10%,k C EU- <br /> Work will commence on or about 4 - rl - 401 for approximately <br /> y S 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 /> I _ <br /> Lti �: 13a� 2.i- <br /> Signature of Applicant - Title Date <br /> MA-7ER.9S'.?c3SC1ML (SiJ=Ji <br />