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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date — I /111 /7-013 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 61114; <br /> P A(A FL-1[. &AS ANA FLF G.T121 L GD VALID _KO " / DRIVEWAYS: <br /> (Applicant Name) STREET �P1Qu� f 1 <br /> AREA ,sG a x/ QUAD <br /> 8 S O S n LLW Am 12 Otto. TYPE ake. <br /> (Mailing Address) FORMS ' ve=' <br /> NOTES ' <br /> EA-)C-sr S ALaL44-w+E noTD C-A 9 S t.c6 <br /> (City,State,Zip Code) <br /> RI Lr-760 - 19 8U <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PL6ASE a0Ar°!tL. M5- AT SLiPH@P6E.cpm 0 AL_L- E 14-r <br /> - <br /> 91(,0--7t*o -Igt06 AN c-0vE 1ME yoU2 GrAfcIL Srs z "'ry s Cc ov.0 <br /> /4 Z 110 F I L6 W Iri t' 'tH 6 d 2t+w 1 N eS S . T rt e Y rt-2.6 'T o U 4-A QG E- ra fi4x. <br /> lob f* P M 30 q I I Z.31 STA 6?4r 1101 <br /> P4T&cr MAW66EQ IS -SAIME P/41U 'O %TA (ZoR) AL42'- I[v41 , <br /> Pole RP(cxce> eA. S a� bocce-+%ans 3,�y 20 * Z3 �'1PE�Pr,E•co <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of , by performing the following work(description of work): <br /> it for rl►o Us I.3n Z Y_ ArT UA,2.tou-9 cA--n otvS SG-E OR-e-wigi6 s . <br /> PALE leg PU4L&m&#v rs A-1u d M*1N 1yJ#e tJG <br /> Work will commence on or about 2013 for approximately L o-Li O 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 /> c 2za cc -� - i//gni 3 <br /> ignature of Applicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC(01/08) <br />