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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3)6/,L5-,r,n1i5C9-- 6 - 7 C71 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# IfA910� REF# <br /> Department of Public Works APN I I CR# <br /> L EXP.DATE �/ <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 1�a X a TYPE , l�jltS <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> �Zo� ) 9-q13 --7 2 d C, <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighwaRight-of-Way on <br /> the N side of LOCKC F-R. c, PTC Sq approximately fee ile <br /> of , by performing the following work(description of work): <br /> 4NVJGuy C, N15-vkL-Te Al JM6C 0e --k-Vhq'e LLS-1) AH ("IF06J i 4 ") w) W tP <br /> Q R ri 1 b a-A-6)i Q� AC Pott,.- -MV LAS V\AA-K nl a"I( SIT r4A,?A <br /> rnc�l�rv►�( r�-orn ��s�z��ur�s� Lo�K� � �o WI�STbourti �ou�� �$ <br /> Work will commence on or about UL 017, for approximately to— 1 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 /> �04 FU KA'nl O <br /> //24 IJI,44-� t PwAtz-r �1t,(�6L 171-18111 <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WMMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />