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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7L6/Zot I OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Z <br /> Awarm Pr:xx- VALID /la TO / 2 DRIVEWAYS: <br /> (Applicant Name) STREET �rx �• <br /> AREA QUAD <br /> t C RD• TYPE ��E rl' 1YG <br /> (Mailing Address) FORMS 'Z <br /> 5A C DA EUM CA 95 L NOTES <br /> tR-� <br /> (City,State,Zip Code) <br /> 6so-6�-bs3� <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> � ArKHEp <br /> APN: 2552701-2- <br /> S, vcosT-R �D . @ DoRNAM FEMY RD. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of —5-- K0 RD. approximately feet/mi16 <br /> Of ,by performing the following work(description of work): <br /> NES -ro. boW MWEEP A Cn"=1'rY POt-C AND Ears Mz VAD-ERA 2O <br /> C_tJ6 !gMyclv2>E. NEED To SE'r -MAEF7L RA VAVLT AND 6 36 LIAVLT <br /> N L4- 140kN0'fRE 120 oF:. 'e HDPE <br /> rDNDVMr 1Zj St ,ION. WEA 'to A'Y!"�cN CABLC -t-v �G .POLE L=VX. <br /> Work will commence on or about Z.S 2012 ot for approximately S 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 /> v/2 <br /> ignature of Applica -Title Date <br /> EWU"VWKYAAVMPSENMOAUWBRPMWAPAL"TM.DW(Ot" <br />