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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2. OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110 coo�9- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> M T+ VALID TO z DRIVEWAYS: <br /> (Applicant Name) STREET i rA;� ,QD• <br /> n AREA ,P..9C� QUAD " <br /> OM 70 ELDER CREEK RD, TYPE kIA <br /> (Mailing Address) FORMS <br /> � w 2 <br /> 5MEN�To 4 (. A 95G��1 NOTES <br /> (City,State,Zip Code) <br /> 650-67D-0530 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) I <br /> SEE ATrAo4E.D a X10$232 <br /> 757 5 LTN IV E RD. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighwayRight-of-Way on <br /> the side of approximately f 2 O' femile <br /> Of RD. ►-tiR=5MA N R0. by performing the following work(description of work): <br /> t Lo of -7-0 "rtiSTAt.1_ N.DPF- CONDVTT UDS-5 <br /> I -TQ NF—_ RD� 2 krEST OF Cil(tTS MAN RA <br /> Work will commence on or about 0, o1.2 for approximately 3 days. <br /> 1,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 /> Signature of Apprrcant-T' '� Date <br /> E�dY P6i1lfMRCA�wOpC WUW <br />