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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (Z 4. /Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# DD, - REF# <br /> Department of Public Works APN CR# <br /> c—A>zL o F Tt+M EXP.DATE <br /> l�I ��-�� VALID T6 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 440 W s t L�to TYPE QUAD f <br /> (Mailing Address) FORMS <br /> 5 rt O C K To t,J y Ca., 15-2 04 NOTES <br /> (City,State,Zip Code) <br /> 2-07 • 3Z3 - 9091 _ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pians may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the �s� side of 5. TRACY l3t-v,L>, approximately_ /400 ' dedbue_EOR n4 <br /> of W Lft 1Z.r/Y_R Q,4D_____ , ,by performing the following work(description of work): <br /> 9 10 Cz C a 1,-_S t I h (p Gtv,c_ti o V S �'g r r o OJ w i of e <br /> �x f-eKd Uti.4 Y-0U.f✓ C_U Gi t°to V-0 )c <br /> Work will commence on or about MA R c r+ - MAY ?-012- for approximately 30 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 /> S 6;zc 114117— <br /> Signature <br /> y 2. <br /> Signature of Applicant-Title bate <br /> EY.SSS/�'d�157E2PSEt+.^-iikLtdlM FlR'4Tf3flIGITU'10.�C fl-ti) <br />