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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/3lz o J3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73oos2-/¢3 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 401IS7 <br /> VALID 10 1� 4- DRIVEWAYS: <br /> (Applicant Name) STREETA/&,A ►/E, <br /> AREA :5 k-VAI QUAD FS <br /> TYPE <br /> (Mailing Address) FORMS lvy� lye <br /> NOTES <br /> K/- SA c--rzD. CA05 <br /> n <br /> (City,State,Zip Code) <br /> 61&) -7&0 - 98 1-7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PQM W jOi5�2�v <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the EAST side of 6. Avg aNffe*O+at* 80R/612-1 4eeMtOe <br /> -d"WASUMiJ4TDnJ 57-• .414D E• Noe-e Ax. '. by performing the following work(description of work): <br /> [�►srAc c. * /800' o F 2„PL.4sTtC_ G.4s M41,,./ 6C ± 53 Q GtS <br /> ,4-rrrmP7wp O,P,,�o4 ?n OP&->.J Gcc�rt�4j <br /> kA <br /> Work will commence on or about for approximately /20 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 /> Si ature of Applicant-Title Date <br /> E:IPUB-SV.WMMASTER.PSENCROACHbENTPERMITAPPLICATION.DOC(010) <br />