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FROM :C.AL I FORK I A IJATER SERI:!I:=E FAX NO. :2094640195 Tu 1. 22 2009 =t=:i=;:=F'hi P <br /> APPLICATim FOR ENCROACEME= PERMIT <br /> pbLxgE Min <br /> Date OFFICE USE ONLY <br /> To; San Joaquin County JOE <br /> Department of public Works APN <br /> CA1._1�`CS 33x2. DATL . /o•/•0 9 <br /> VALM •09 To lQ./.0 9 DR2AYS <br /> {Applicant Nome) <br /> •!���. ASA `-�ckTaal Qtf�D � * � <br /> TYPE A3E4e_ R04rm <br /> (b�ailixxg addxGaa) FORMS ✓S G�I+� � <br /> NOS . <br /> (City, Sbatee,, -Zip Code) <br /> (Area Code - relepbone Number) - - <br /> Sketch, (ba.tailed plans may be siubmitted) <br /> The Undersigned hereby applies for permission to.exaavate, coaastxuct and/or <br /> otherwise encroach•on County•Sighway �tight..of-w IN <br /> LA 'F'��,,,,L�'"CY'�' aye oi�•thec <br /> o f approximately ��„�. /en**e <br /> lowamg workesc xptio ' ' by pe-rEoxmi:tg the <br /> xx of;work) . <br /> _ W <br /> 1t lfr ` • . <br /> 'Work Will co � <br /> mrneace- on Or fox• approximatel' <br /> ---�4 gays, . <br /> 1, the undexsi!3ned certify that I am the owner rof,the respective property, or am <br /> qualified to represent the owner and-agree to do the work descried above in <br /> accordance with the rulef, regulations,of <br /> inspection and approvaSan Joaquin G6ux�ty and sub3ect to <br /> l,. Qlq� 1~0 <br /> Sig4ature of App:,i.cazrt itja n_ <br /> Bate <br />