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5l11 a 010 -if- LVtv.r w I <br /> 1A 00"t" BuCWPLn Rood Sy%&qqt crepla�MMtr+ <br /> a� t4 0TVA ForK aF W- � <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date gl231 14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# P REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 — 20 1 t,If <br /> Nar"kbur" Co>n mfina VALID is^13 2v ATO (�rl _20tDRIVEWAYS: <br /> (Applicant Name)J STREET <br /> QUAD <br /> IAR( p0ClWQYI hVG• TYPE �t - <br /> (Mailing Address) FORMS �S iy (ZZ�I' jr�,.C�—CAA-�f b- I <br /> NOTES <br /> (City,State,*Zip Code) <br /> a14 315.b-1041 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SLB SITZ✓ <br /> DE� 1-r2lqlcc <br /> 3 0'? <br /> Fat <br /> The undersic ned hereby applies for permission to excavae,construct and/or otherwise encroach on County Highway Right-of-Wayy on <br /> the e v side of 0.h IL011approximately I.214 fee i e East <br /> of , by performing the following work(description of work): <br /> Cl will air-M4104 a 2 e tork+oN bbrA%Aq& it avoMs off- 40-U0' btJb <br /> ILYAWY14 91 e. 'n -10i tl u s. \01 wtpl2S <br /> otlr-^,s" WI SPT CA MOD t C Wf I I b#kV/-fft ev, <br /> Sah-Soa ftW1r6V1VAiS.W11 CV5 Willlnn a c ew1 <br /> o++Sqc &r voys "ftUrA 'gel Witt ofto Ari 2 s of <br /> Work will commence on or about 2.01 tA for approximately 1 days. �( <br /> the un WMAN't +VV, � 1VA" SVA0ul.dt'. <br /> I <br /> undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree tb do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sign ure of Ap licant-Title Date <br /> M.ICEMRALSERVICESICLERICALIPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />