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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# E t 600< REF# <br /> Department of Public Works APN CR# <br /> ��7'tl2 11,"10 EXP.DATE <br /> 2o14 <br /> 5 _ - - VALID �► TO <br /> Zc�14 DRIVEWAYS: <br /> c 9 <br /> (Applicant�lalej STREET �czcs►s� S« t- <br /> ' AREA - <br /> r1 +.t QUAD AjE <br /> TYPE -��iv1P i�aAD C tosi�»2E <br /> (flailing Addf Ods) FORMS <br /> NOTES -- <br /> (City,State,Zip Code) oLr�ra�P B>z.�4T► - � t, - - - <br /> 'Zu`l -- y �Z-(�, `/cY.7 - tee.. I2 �,► �"cia+9�_ , <br /> (Area Code-Telephone Nudiber) <br /> Sketch(Detailed plans may be submitted) <br /> f <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -�} sidCeef -r�u�3 0 L FrLoi-Jt s; approximately feet/mile <br /> °f by performing the following work(description of work): <br /> �t�Tl,.s I=�-t\, _ i3� N i•�.aM� S �s-T rti1 �. <br /> i S Tom. 0 l b FIz9 C�L ( 2&1 J <br /> F(Lc)VVI • Pu r1 l40 L I t0 i C€L=--g R-4-77 ori. <br /> &'TTF-- . 6202 Q Y 774-0 ©+M M u AJ 1 7-111 <br /> i <br /> ------------------ <br /> Wor!<will commence on or about >r.C�"'Y✓1 c�'t. - '��� fior appraximately <br /> 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 /> Sign pare of Applicant-Title Date --- <br /> FA:10EWRALSEWCESICLSZICAL1P11BSV-WKVMSTERPS1El.CROACH;1E17TPERAIf(APPLICAIIOMOCC(09113) <br />