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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2,112- i 3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# f�D�.� REF# <br /> Department of Public Works APN J CR# <br /> EXP.DATE AM111 15 <br /> Chas NeISoY) tr MyQrs anc1 scc,a VALID TO / / DRIVEWAYS: <br /> (Applicant Name) STREET A) 9 ig )w <br /> AREA 500 VeArad QUAD - <br /> 255'1 V`illcrcel-- Pc+ve TYPE 1AVIZ6(JIAI& $,aA.41 409-,p7 <br /> (Mailing Address) FORMSwi✓ <br /> NOTES <br /> Sactrty f- 4Vl 95663 <br /> (City,State,Zip Code) <br /> 91u- (.ey9-gS0Jg <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 Right-of-Way on <br /> the N;+�,c 5 side of wur�d Ave, �; t M� approximately feet/mile <br /> of `"�'�'f` ' `'"a"' "r''n �' , by performing the following work(description of work): <br /> 1V`kr) ttV.F'ron}a�c Rte, liom +-YYU.cn and `1�'►a►-rno c a5 u as /�-Ec�i rvc w4*�- ✓�r- <br /> � <br /> u4- cv-Cwctic on W• F+xxtac .. WI&n 4YlvnJ.r4 Nub �crr► t Qq t C4ylarys i:,cluc�tYt r e c�v� ✓ Ic�e� <br /> 1-j11iA qua e 4'-- Q} Dc.1?--Cru1L 8oufh L LU1cVl. W,&tn ql'1arlPc6 Rd m t35 fa cf►7w id ' ciw6riy rrgiaye catol �-pIa-`e <br /> O} Tur(pasc,. Ave Err_ �+ i4wy Q� �-crl�GM �jc�lc�tr► ��z� q-ye. and MWve- e cddtn 6ak A-vt 13^ and <br /> 411- nq VVn. (:i-t v>v an&v 1a- oo C r �tnL lwc_ g�. <br /> Work will comme ce on or about a� W13 ( f+r /5c k for approximately I/5 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 /> Zliz .i3 <br /> Signature of Appli nt-Title Date <br /> E:IPU8-SV.WKIMASTER.PSIENCROACHMENTPERMIT APPUCATION.DOC (01/08) <br />