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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: !� <br /> Date (, tC t` <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11°005`— REF# <br /> Department of Public Works APN CR# <br /> �V'V EXP.DATE . 7.09 <br /> VALID $:l?I TO DRIVEWAYS: <br /> Applicant Name) J STREET VArjDUa g9pn3 <br /> GC' s AREA 1,*0"A" QUAD u W <br /> J11 J0 tyst 'V" 00(10(kY-'Y-' TYPE <br /> -ra1Mllp. RoA3`y CCASttAE <br /> (Mailing Address) FORMS <br /> NOT <br /> —;� .o �a� �• <br /> (City,State,Zip Code) <br /> t , <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ( �JkN JG k-Iliz0 0 <br /> 2 <br /> The undersigned hereby applies for permission to excavate constru t and/or otherwise encroach on County Highway Right-of-Way on <br /> the_�ji r✓h sidesof 1 z 02,4 fOW _approximately feettmile <br /> of <br /> . by performing the following work(�descri tion o�work): <br /> e ,� c w <br /> t ` vs +IWOO <br /> '6v wQ 12t fOO )It 7 C 2 <br /> Work will commence on or about_ a C for approximately d- day . <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 11-Title Date <br /> E`PUaSV'4KMS"TER PS.HVCRCACHNENT PERMIT AF: ATk]N DDC r0i/06) <br />