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APPLICATION FOR ENCROACHMENT PERMIT <br /> pLEASE PRINT: <br /> Date 112 7(3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# //Q REF# <br /> Department of Public Works APN i CR# <br /> EXP.DATE /3 <br /> aOMCAST CI O&E VAUD D 3 /3 TO / I DRIVEWAYS: <br /> (Applicant Name) STREET traeI6)16, <br /> AREA QUAD • <br /> (0505 TjqM 051/A N7ep, OR TYPEAil-e- a • <br /> (Mailing Address) FORMS jvw• .z Y a � ' <br /> NOTES <br /> �1ro�KToN GA 4s210 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Ssr- K-rrAcNEt FNe-/TC. IPLA06 roi, brv'i'A I L-S <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the EA ST side of bit I"RY aLAc F— approximately 261 a il8 No2TN <br /> of CAir Sey PLkE by performing the following work escription of work): <br /> AS sgrzing—b oo -Mp— C,QAIST2UGTjoQ pjjVN'- J.& SOQE VZOM r—X1ST K)& nl'x 30" C,A,T V. <br /> V WL7r 140,KMA QL) 0 AIGS11V PLA GF— 40MV -m EIC/SmJG ' OW& xt"y-r AT 3b"M I W t <br /> -WO" AAAV DEP'i'N, =NSTWI-L DNS ?-" OND017-- Rig M-)c7tpLe SIDeWAW, rt'ACss &T+(Ot-E <br /> =N 5 S D L j AJ& 0 u r+T I <br /> Work wilt commence on or about n s A p for approximately As&P days, <br /> 1,the undersigned,cm*VW 1 am the owner of the resimfive,property,or am quaW to represent the owo and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaqurn County acid subject to InspecWn and aWmvaL <br /> 4Zfg= L4fM►T C0kb1A1,47DiE 912 712013 <br /> S6 ofAppkant-Ttde Date <br /> thr, Layo v <br /> E" f$J!!/W[pITEltDOG own <br />