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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S '2`j I-X12 OFFICE USE ONLY <br /> To: San Joaquin County JOB# _ /OGS REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> ,�� S/S 2 DRIVEWAYS: <br /> - �� VAUD � T <br /> (Applicant Name) STREET 2 . <br /> Q�NT-�S uV. -7 AREA �'raCkztsn! QUAD <br /> TYPE <br /> (Mailing Address) FORMS lTp <br /> 9,5219- NOTES <br /> (City,State,Zip Code) <br /> 650-6�0-f�530 <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 Highway Right-of--Way on <br /> the SoIrTF{ side of W LAI I,M► DR. <br /> Of approximately_j f'e ,k feet/mile <br /> �� � P��ttJ; Zig >UDIDl- by performing the following work(description of work): <br /> 2`131 � � AiAl1Z"T Btsrt�.�r,►i Zr z- 2m- NLe AND _ <br /> 5 d-6(v Ute?l.T itiiT� bE w�ruZi"TS�W. A Sn i - <br /> ��R�trt'URE <br /> Work will commence on or aVUt—qtzN12 _,for approximately <br /> 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 /> l <br /> 3�ZD <br /> Signature of icant-Title 12 <br /> a�ote <br /> EiUB VWAVtMP6*"W40kpq PeMI APPL1CATON DOC to=) <br />