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0 ,,72-05 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date q lg 3 l OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 0)S ; REF# <br /> Department of Public Works APN _ CR# <br /> PG&E EXP.DATE -(5 <br /> VALID — TO 10-1 1 S-I S DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 4040 WEST LN AREA �y1 Q AD _CS <br /> TYPE <br /> (Mailing Address) FORMS <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 5-) (0 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH <br /> The undersigned hereby applies for permission to excavate,construct andfor otherwise encroach on County Highway Right-of-Way on <br /> the S/ side of !�. a fz�CDl e'tl Gt (A) approximately 3 5 -- !0 0 fee mile�— <br /> of Fl LSEIZ'r1 G'� by performing the following work(description of work): <br /> 1,V-C1-AL-L- ryc'-yJ DCAINA i^Aai N f. <br /> Work will commence on or about for approximatelydays. <br /> I,the undersi ned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work describ d above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> nature of Applicant-Title Uate <br /> EIPV&SV-lVMI,1ASTERPSeACROACHAIENTPFRId;TAPPLICATIOI1DOC(01100) <br />