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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /0- /.2-/S OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> PG&E EXP.DATE �4 <br /> VALID 16-14-21-,X-TO DRIVEWAYS: <br /> (Applicant Name) STREET � X. <br /> 4040 WEST LN AREA - QUA`D <br /> TYPE �� 1 <br /> (Mailing Address) FORMS <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 408-316-1767 <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 and/or otherwise encroach on County Highway Right-of-Way on <br /> the .Sour'// side of L.1A1n./L RD. approximately 550 —feet/f44 EA-92- <br /> of <br /> s%of 0-IRI-Tm wx/ !1' 7-1PAICV _ by performing the following work(description of work): <br /> �xcs�y�y rc syDLE ©ciC.2 �JQ.S rYlvic! iy,y� L'uT DFF SE'2t�'/CE. <br /> Work will commence on or about //-/L -/S for approximately 90 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 /> �czZ, A E: /D d/2 /5 <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />