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t J <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ('//K/Zv l S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 2, REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE `7-(-1� <br /> Tc( 1;n— Cori T1/ 7/f VALID 6 2$-I S TO 7-t (s DRIVEWAYS: <br /> (Applicant Name) STREET �> Rd <br /> AREA I QUAD <br /> 3 /¢ve• TYPE TCP <br /> (Mailing Address) FORMS <br /> NOTES <br /> LA-,O r-� /c: C,4 015611 <br /> (City,State,Zip Code) <br /> �g/O 7/ - 74 65 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) �i <br /> -76'- A H"CA,el c+ r C, <br /> Tr- F>�','� Cor?trQ Per' tle Afl-,-ti6J- stiee�'.s <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> P( wes; oP Jy Bele,- -e ilelilr- R ! Itc (/ <br /> l�eloe. <br /> Se,;,ven)c Ones r nsi of Geo/ 4o e s Pl,;tcd On i-Ae _arm 'JJ J1 'rp"re . e-a,Eh E46� <br /> 1"A.; :s 1.50 �A u 'I'l fAcy,fe1 on <br /> Ivi w,r-A, Prate sed <br /> Work will commence on or about G/Z /z I3 for approximately 2 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 /> E'.PUB-SV WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br /> pfa, � ¢ ?,U1 y— O 17-I <br /> > &,--rn,� Y2-o4-0 <br />