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APPLICATION FOR ENCROACHMENT PERMIT <br /> I <br /> PLEASE PRINT: <br /> Date U1��2.012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> partment of Public Works APN CR# <br /> n � EXP.DATE 1711111-- <br /> fom--CA5T- NNowed K — VALID I3 IL TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA.. QU'� � ' <br /> t r7O UM9CWWEK RD. TYPE <br /> (Mailing Address) FORMS LV -2 <br /> 5ACMMGWQ , GA 95 aLf NOTES <br /> (City,State,Zip Code) <br /> (�50-6700530 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 15,� A7MCRF_0 10 g93C7 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwayy Right-of-Way on <br /> wa� <br /> the 5OV714 side of W. LXNINE. RD. approximately S7O-' fi'ee�mild�� <br /> of S. MAt4tzf}tl9e DR. by performing the following work(description of work): <br /> 65f <br /> OF: 602.F—: L-a-n1=N G'AJM-( 2.O.W. 'fO =M-97-A" 2�� HDPE <br /> C.onADilr't" AND rtJ, Aic, 'I�J4FF`lG UAUM 7W THE 5140yLPER <br /> Work will commence on or about 1911: Zot 2. 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 /> Stipa a of APP_ rile Wte <br /> E4U6S MVMSMRPSe0WzW TPHiU*KCK7 KWC ot" <br />