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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /ow/i2 OFFICE USE ONLY <br /> / <br /> To: San Joaquin County JOB# QaR d\npd 5 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE 201 2 <br /> 11ne Soy�c2 Gtco�Q, 1r\c.. VALID S-2&1/-To IJ--V 2C 2_ DRIVEWAYS: <br /> (Applicant Name) STREET R <br /> AREA QUAD 61 <br /> °►""'� MC'C0VAC\ . A R�S. TYPE 2 M ►vz • W k <br /> (Mailing Address) FORMS <br /> NOTES <br /> Crco ss VA1kp, GA 0�59MI <br /> (Cit),State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the nactV% side of Cop�eco�ol'is \Zoc,.a approximately �-2. fee mil west <br /> of C'V. v Ne- by performing the following work(description of work): <br /> L-effc cun �iree- :6"'0o,-a,... T . <br /> t( �or/haS �Q.r- <br /> 0�1� around�.a�!✓ SQ.rOle f. ��iPc�t P.ae lOY ! foci!✓S �UnG� rG'24/rtrrrtn� ��.Z�000 p!� w¢1�� �3OU <br /> C�n�iaac M+�e� fees t//!3 oe- fee. /yoni laelno c.re//s c.�.1/ �i�ls�e� i�+ a <br /> IF7Yaf7ic rGi'/�i� iA.rl/ bar �o s'[er'lac2 �i✓Aa�e. <br /> Work will commence on or about 22, 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 /> /41// 5-G, -V Sc;uta,s� <br /> Signature of Applicant-Title Date <br /> EPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (O1N8) <br />