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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date m kK I � I ZD 12- OFFICE USE ONLY <br /> To: San Joaquin County JOB# �. ��,. 2 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / IL <br /> U c.121 LF�tJl) VALID /$ JL 0 $ / DRIVEWAYS: <br /> (Applicant Name) STREET t QD. <br /> { ' AREA � '`�^'� QUAD IV,4 _ , <br /> TYPE ,v <br /> (Mailing Address) FORMS <br /> NOTES <br /> �S <br /> JV <br /> (City,State,Zip Code) 1?L A40jnNt45 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SI«T\A&S I tV C..LU O c_!J . ?_o P,o P �_ _ r10 ��rev L <br /> TC) gr �Ca'�p` K_ TH /N k-\f�1 L Ate i i-OSI�(�. <br /> (L F L K&C-t_r.cZ� �� i L t_ r s C L/��i C ,''{ ' P I_f4�C_.E_J <br /> T1_G"'C [,a te �� .. o k o 0 C_C)tjC)k-V C)/J <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the NDfZTtA side of CILLI �� CAU approximately > l4 fee 'F2Dm C/L_ <br /> of C-C)LL\4 R , C , by performing the following work ascription of work): <br /> T1�'F_(QC" 0-IN6LE_ JET 30 FST LEP,-:)T 4` DAF Dr. r,--T \JJ . <br /> L7t� rtk t�lC. ".` ��� T t► 5 =." �Ji~; ' �'..) 5K i�TCA46_S . "A\0Y �2_) : L K)_L:' <br /> F its L 350' I'YL CA- Q(-_ H to V PAV D 0V_\y E t)J k1f S <br /> �0ILL �_10R2E-0 . r;_vZn0 iAh!c) 69i:_t`�� <br /> Work will commence on or about-A42 115, 2 U 12 for approximately 30 days. <br /> JL NrE <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 /> gnature of Applicant-TM—e Itte <br /> E:IPU&SV.WMMASTERPS%ENCROACHMENTPERMTAPPLICATION.DOC (01/08) <br />