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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date QGT. I Z . ?�b041 OFFICE USE ONLY <br /> To: San Joaquin County JOB# MOOS- REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE M E.09 <br /> 5.5. .E . 1 . _ VALID It-IS-.09 TO 32.1-0Q DRIVEWAYS: <br /> (Applicant Name) STREET K,�Ac.E R,a. <br /> AREA g4jkt,t,-_) QUAD <br /> 1 1 0 1 1 E. H I U H W AY I ZO TYPE 79C)Or� <br /> (Mailing Address) FORMS <br /> NOTES <br /> M A1J-TE.G,3, GA g533t <br /> (City, State,Zip Code) <br /> 2,001 - Z4!- 44o0O <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> J ol. <br /> Q 3 ENc.RoAcHMENf <br /> N � b.J• R-I PoN >z�. <br /> to � <br /> The unde signed hereby applies for permission to excavate, construct and/or otherwise encroach on County Highw Right-of-Way on <br /> the side of A L.ic f-- IZac.o approximately 1000 fee ile We) <br /> R <br /> Of -I Po n1 20 A D by performing the following work escription of work): <br /> RE M oy F R•-.PL-,&-e-,E-. 4e:." G I P f IBJ ITN Go L Int Ems- 'F E'I y�T <br /> o GLASS <br /> IV F-,ex R,c.,P 10 c o v i i-r-r 2.t cm i-4-r -a - 6-ug-r. <br /> Work will commence on or about M 10 for approximately 14- 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 /> ..._. <br /> ICA- - <br /> Signature of Applicant-Title Date <br /> E.PUB-SV.WKIMASTERPSIENCROACHMENTPERMRAPPLICATION.DOC (01/08) <br />