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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -iy Lv 29 20 t4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ._ Lc1 �'' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 'L <br /> RG,yJ coasT"(z-Ttotl lsAO- • VALID j1 TO - 0 DRIVEWAYS: <br /> (Applicant Name) STREET e`c- <br /> AREA LtId ;_ QUAD �yV <br /> r7 S-b &f-EEAuLLC- RoAD TYPE <br /> (Mailing Address) FORMSS <br /> NOTES <br /> LN E?-Mu9-0 CA 945-5-0 <br /> (C y,State,Zip Code) <br /> `3GoG, 24vo <br /> (Area.Code�� ber) <br /> C,k.L �•� �oto.�14.8 -a,4!a.eZQc�. � � � � n.CCA" <br /> Sketch(Detailed plans may be submitted) <br /> 90eAga H E`t� �2 s+�EETS) L-o�.1 <br /> sA�-A�� cam. enp►�o�l�E�-t� <br /> puz>J ecT. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the t4ov.Tt4 side of 6 IMtt-E- F.D. approximately 3 fee mil <br /> of t-OVAOL SacRa. Ca 44D" , l-0"01 , by performing the following work(description of work): <br /> c�tzla� coF k StV-kL,-t c OAC94 E tZ-0"W3A.1, TD 5T1W C-Wt.A'L' <br /> SP CXtbh\ -MC-LAESc &Ab QOP-LI 't 3 QP lr-t41ERA41__ Oc,02S of -0 -bFFtS- <br /> colio-IT LOL 4 c-oJ?=to C7 tS ':-3 Atm 3 a M <br /> Work will commence on or about JJL.\-► 3o Zo __ 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 /> Signature of Applicant-Title Date <br /> M10ENTRALSERVICESICLERI.111P B-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />