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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# /%f)p,95 REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE / <br /> CITY OF 4A`rNpoP gyp±Tl VALID Imp 110 44S /l DRIVEWAYS: <br /> (Applicant Name) STREET xye t <br /> AREA 40W epoP QUAD <br /> 3�0 TDu}r�� C.ErrT L TYPE 4�y"Al <br /> (Mailing Address) FORMS fyyV <br /> LAr i eQP, CA 0153,7,a NOTES <br /> (City, State,Zip Code) <br /> ZS29- Ctkl-7k5� �2�.�I- J1Z-o733(ry,� <br /> (Area Code-1felephone Number) <br /> Sketch(Detailed plans may be submitted) o.ZG AIt-gTo Mc.Y-rAl46y <br /> 'Q�+�AN�r>T +'LPJG G¢o55tN4 <br /> Wf"Ly <br /> ---- --__ k YE 1 S2 E w.a✓E C> jZ�bd <br /> ( ./- <br /> i <br /> 0 <br /> 17-" PIPE. <br /> 0 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> $oTR side of °{moiTV- ArA;E approximately 0•Z5 feet/mile wEST <br /> ofC 1s%10l,Ey A-V e , by performing the following work(description of work): <br /> C ON Ajr_Gr TD WA--TFR_ 1,4&JE 1n1 jJpR1N SIDE of <br /> ti J oS E-e41M p"G45— <br /> I"7 tle/ 17- <br /> z" S V A-pa Iz �6b Pvt / 42"OKSr/J4 l62 YAS9m i 1�5 .fit, 7-o 6a44-7N <br /> V W Li CONN ;- JVMAp"k]� IZ' P/P "A)eAT <br /> 9-P, Pee: <br /> !% mqzAili <br /> Work will commence on or about for approximately days. <br /> /2 Zoe/ Y <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 /> f S tl f f i <br /> Si ure of Applicant-Title f ate <br /> E.IPUB-SV WKIMASTER.PSIENCROACNMENT PERMIT APPLICATION.000 (01108) <br />