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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / Z`1 12 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE D /all- <br /> PG sl G - MA-ft K ik.AW A VALID 3z r2_ T c. DRIVEWAYS: <br /> (Applicant Name) STREET wine- !g& <br /> AREA � �D60UAD NW <br /> 350 �.W��i�i ik*3�,5��r� 2_5 V TYPE T �,rc�mk '(a, �►lo pan <br /> (Mailing Address) FORMS <br /> NOTES <br /> W m-,,Ivy c iL is c A 614-5 9F; <br /> (City,State,Zip Code) <br /> 'Sio - 10G - IIt0 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SFj_- }�►TirGI1 + i� +-oc il�v f s r r=at Carte,jL0 _ P�r�:' .Awl Ric'�►,►v HYenc si <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the SO"r14 side of MokG Lum,yC 5 # wmaao-iocc 20 approximately feettmile <br /> of ,by performing the following work(description of work): <br /> TfAfFtLCOnirtpc- . CXc.WhTWJ J>> Grti tIPt;-4imC_ N;Ofio'i s1 oaa L- ly1b, Te r T-ICct-IL. <br /> PIM* `�t1b5620+ <br /> Work will commence on or about -71301 % 7— for approximately C_ 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 abo;in accgrda ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Si nature df Applicant-Title Date <br /> E:IPUMV.WNUAASTERPSENCROACHMENT PERMIT APPUCATION.000(01AB) <br />