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APPLICATION FDR ENCROACHMENT PERMIT : Ch <br /> 2115 SEP i P 2 <br /> PLEASE PRINT: JJP T ? i i is W O R EK <br /> Date -� �/�J OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 jaO �-2 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 /- r-- 1 5 <br /> SAG C GAS ` E t-E G't� C VALID �� TO //-/—15 DRIVEWAYS: <br /> (Applicant Name) STREET "7-4 2, �A Lu a ye�� ± <br /> AREA S QUAD 5; <br /> a R1-4 E(Z P^R. L. BAST TYPE 'Ifb <br /> (Mailing Address) FORMS !i, <br /> NOTES <br /> o GA ''t 3-Z0 <br /> �tv` Jul (City,State,Zip Code) <br /> Ss�I- <br /> 3>4 -7 -size <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ia- CN c2 U AC A4 S 1 T E t�C_AIQ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> tha5Wik)gA�<W4'Fe of 7�+�+'n As*sr, #,�c sr�•p•'sr. approximately 3002! (fig 'mile <br /> of 2"'WfeLCOL.AC1 NMr+:)4AS Pi V'E ,V'PLA5-n4-GHy performing the following work(description of work): <br /> Pc-4 CF W%(,L rzep--okcLT- E1I rST)N 0 Z'' srECt_ Cs.4& mmN S AyrID /NS74C4- AIL-1-KI <br /> Z" R./►STiL 4*-S AM47/4S ON & 7f4 ST. S•`Autt,FZST S• ASN ST. S "p" sr. t <br /> S•"g" ST f Sr0cY TDN LSAN 3o,4@�t J Nri <br /> Work will commence on or about a —14-—ZO VS for approximately 104- 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 /> /11gnat re A pplicant-Title Date <br /> EPA-SVWKIMASTERPS'ENCROACH4EKr PERWTAPPLICATION.DOC)01)00) <br />