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APR-19-2013 13:40 From:12098391796 Pa9e:1f3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date * • j OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 13 <br /> VALID 13 o 1 Y3 DRIVEWAYS: <br /> (Applicant Name) STREET eVP-12 OV <br /> AREA 1 `t QUAD 150 " <br /> 90 S Tro.c 9 W , TYPE o1.E <br /> (Whiling Address) FORMS is o, C.uTA <br /> P �5 r_ NOTES U�y <br /> (City,State,Zip Co ) �P <br /> , 9 5"s-od w <br /> (Area Code-Telepho a Number) <br /> Sketch(Detailed pians may be submitted) J,b:* <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the t7 0 r� eo' side of approximately L4 fee mile <br /> of e- o e ,by performing the following work(description of work): <br /> 5.j? e <br /> Work will commence on or about for approximately Y 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 Applicant- le Date <br /> E�Pu6$vwKW8TERP87X=ACHktV-r PERMITAFFUCATIDKDOC(0i" <br />