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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J-ly-/,Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# '\p05_5 REF# <br /> Department of Public Works APN 2 S 7-oZ o _ c,y CR# <br /> p J /� EXP. DATE .5--j - 2o/Z <br /> Aoagt1on U'U,QiYt'Sma VALID �-l- 0-OaZ-TO ;5- 1-2DRIVEWAYS: <br /> (Applicant Name) STREET P YYt r► jU- <br /> AREA QUAD S <br /> 5300 E. rrin TYPE _P <br /> (Mailing Address) FORMS wT(�Lq <br /> NOTES <br /> INan�cuc 01 95337 <br /> _ (City, State,Zip Code) <br /> z0q 82s-777y <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> $ee ail4c4ed maP <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> theA1#o,AAok1h side of Pc rrbi Ell, approximately M 4 feet/mile N*S-7- <br /> of &AZZay ,ez>. by performing the following work(description of work): <br /> oaS rac —a—Al trP;04141 <br /> rrn n a rri n r � lva h rri atlime -J At irri i�pi lint Will 7� <br /> irtigp !u7 waw fo criyl+ across ar an ?ke oro�u O�ncli•� willbt <br /> 2N <br /> Work will commence on or about_ 3 z �T o? '�- for approximately .2 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 /> A014Yv�-- 3 - �f ?� <br /> Siffinature of Applicant-Title Date <br /> EAPUB-SV.WNIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />