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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date A4y 2G 20 9 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7605-K- REF# <br /> Department of Public Works APN CR# <br /> j� EXP.DATE <br /> CIT'( pFa�ItEGR — ` UFL1G WORKS VALID . 7,09 TO //./$'69 DRIVEWAYS: <br /> (Applicant Name) STREET Ati AV 4 <br /> AREA QUAD <br /> 1001 !/y. C EA)TER S T(Z.Ef T' TYPE — AIAW <br /> (Mailing Address) FORMS .Z R <br /> A-NJT EGA 0 'CA _ 9533-7 NOTES <br /> (City,State,Zip Code) <br /> (2 09) 2 39 - ze 39 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the EAST side of AU5'rtV ROAD approximately feet/mile <br /> of by performing the following work(description of work): <br /> u <br /> A.sTrnl Rtoo+p PQoM L&THf-op tkp To Y09F 1,M,Tr AVE <br /> Work will commence on or about J�1LY 3 , 2 d4q for approximately co O 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 /> SEnllo(L �NC►inleat: 5-26 O'� <br /> Signature of ApplicantTitle Date <br /> ,C6,W.W'00 ULL-OA <br /> EftIR-SV.WI(IMASTER P&ENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />