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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 735/-a REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Z <br /> V ( t zo Iy - PA tJ t i L VALID /s- TO / DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ' '' 11 AREA N AIrfte-�4 QUAD � <br /> W TYPE 'ALL i-{d1-ES Izoae <br /> (Mailing Address) FORMS <br /> NOTES <br /> _� �` ��1 J<7-0 <br /> (City,State,Zip Code) <br /> CZCDC�)3 Z367)03(0c� <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) :3 f �! (cxNcT LOC n F V Z <br /> VA1� ��k PJ ``I 1 I C.kBIE- -7& 0' WE <br /> UJ I L L FIND , I N37 LCE P 1, <br /> 22 <br /> CSL l_ 4 I -:� '1 <br /> -D?U(-�- BOY. <br /> S6 .� <br /> v <br /> X10 SCNLc^_ <br /> The undPrsinned hereby applies for Dermissinn to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the_e�-44Vk . _sidesof�oc�c T6+0- �-C) approximately ES' fee S00T H <br /> of L'/L , M A,(OTE-c r� , by performing the following work( escription of work): <br /> r`0 n-N �-- E-r�c.L 4-I I W e.5-c r= C F. L 1 ry 2_ n Pc Y-To r,-)eL <br /> To RPPK-0YQ rnkTe-LY 3-7' LP,s-T nt= C-/L <br /> P --S UJ 1 LL (� E- 4, y,,6,' q r3 0Z-- W i t_L u�_ A� 3ca,�_ 2�„ C��.cn �� . 71a)ca <br /> .J" SU Ofl f�CTS �� €_t_ Lhrr__ <br /> W I L L P L P�r—' E.(D A-T- Lf,3 0 s. - <br /> Work will commence on or about for approximately 3 days. <br /> t5W5 - <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 /> 2 ~ <br /> .1 J"FADi 0—'VEA*3�( I FE 11 <br /> 1 <br /> Signature of Appli ant-Title YDate <br /> E:IPUS-SV.WKIMASTERPSIENCROACHMENTPERMITAPPLICATION.DOC(8108) <br />