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.�' rof- C0w16AS7-1k <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: PS - 130315'0 <br /> Date 1/-,:,?7-13 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110005 REF# <br /> Department of Public Works APN CR# <br /> n EXP.DATE 1 j;/2-0 14- <br /> -P&P, Y AgfWcd VALID 17./4/Z 0 1 TO l SI 0 DRIVEWAYS: <br /> (Applic nt Name) STREET Ave ' <br /> AREA i-pC k to QUAD F-5 ' <br /> !!oip BlejSA Sr TYPE <br /> (Mailing Address) FORMS S S/ L,/rte-2-ef <br /> NOTES <br /> Z'llcw�#10&2 6A <br /> (City,State,Zip Code) <br /> t'9o25)a$C1_ 4138 7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) � �� � <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highhwway Right-of-Way on <br /> the 6k;r side of svgg c A V6 approximately _j5220 C fedmile A62&A' <br /> of F- F GXi01Jr ,fit- , �GZIW ,by performing the following work(description of work): <br /> rAom al" oG.& S04411 OF 00/ 0.�5 AV64 14 <br /> 35' A,1:7/Li''14 e D 7 .--tau -1Z -"WW EAs r Tv /aot 5ro rc A vE- <br /> /N$ f".?' 6O&J'"1�141-r FP Q z-,Aw ise f-yizZ <br /> Work will commence on or about a-!2- / 3 for approximately , 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 /> , 1�T G�,eD�NATcs� Z .-?7 l3 <br /> ignature of Applicant-Title Date <br /> MICENTRALSERWCESCLERICALIPUB-SV.WKLIUSTERPMNCROACHAIENTPERMITAPPLICATION.DOC(09113 <br />