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t <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9L5/2012- OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1/DD05- REF# <br /> Department of Public Works APN CR# <br /> COAACAS'7- EXP.DATE 0 i 2- <br /> VALID 97P71-z- O O-,45- DRIVEWAYS: <br /> (Applicant Name) STREET &W W&g "• ` <br /> AREA A4AIrIEG4 QUAD �jE ` <br /> 6505 TQM o SHrtIVr6C Viz. TYPE 3W As <br /> (Mailing Address) FORMS s yva-J <br /> NOTES <br /> e;-T0- Q--MA) GA 95210 <br /> (City,State,Zip Code) <br /> X50- G-70-os3c? <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 107 1 � <br /> N=C-E- GA WEN �Y <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach or��Wn <br /> ight-of--Way on <br /> the `!�QQI�1-( side of F-. N?LE ?=D. approximately (- ild <br /> of by performing the follption of work): <br /> NEED 'ro R. R 3 Y--G' OF A-SPAALT- TU ACCESS E3e:3757--XAl Cr <br /> CATV PEAESTAL— , '7NMLC. INCA/ 27 NDPE. 60k)OLar, <br /> GET VAULT otos km om, pko P I- ATY. <br /> Work will commence on or about 2J/ for approximately 2. 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 kr accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 9& fZ012 <br /> of ,K-Tile Diate <br /> EVW4V PMffAMWAW DW P <br />