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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 60c,,f REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /— /S 2C)12— <br /> TiXe Source, G,ouo, ,Znc. VALID (^(-2,gA Z TO (—/,y-20 YZ, DRIVEWAYS: <br /> (Applicant Name) STREET C6 gpey-o(jolt 5 <br /> AREA QUAD <br /> y cege'A O�. Sc,rhe TYPE 3 <br /> ( ailing Address) FORMS <br /> // NOTES <br /> C.7 n, 4A/ . �A 9S9Y9 <br /> (City,State,Zip Code) <br /> rS3o)Z72-S��ov <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �C �T7Gcn2ti( <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -54,.- + side of 6,,A wrane/,r Ro% approximately /.z feet/miles G.es-I <br /> of 5-a_-1, Jack Tolle. 4&Z by performing the following work(description of work): <br /> �.'oII.., 10./�/ c��a c.Eec! �i�,.e. L✓e��c <br /> G.C!/ is COi110//e,16c! US,.1 i7 n �GG4- ^otU1�� do-4 /.6, ., T/l fVc /'47Je� 4.C��/ �Ofy �' G✓ �/ <br /> b! �ilarc To-/ /Y, co."e'e-/e a.s -# S W lace_ &-g-1 <br /> Work will commence on or about .10/1 for approximately 5 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 /> Signature of Applicant-Title �� Date <br /> E:%PUB-SV.WKIMASTERPSIENCROACHMENf PERMIT APPLICATION DOC (01)08) <br />