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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Q G-T ( Z , z0an OFFICE USE ONLY <br /> To: San Joaquin County JOB# lbn� REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 12.1.04 <br /> G> 47 1 , D VALID �\.15-01 TO tZ. k.pg DRIVEWAYS: <br /> (Applicant Name) STREET SqcTa vJ 12r->, <br /> AREA QUAD SiE <br /> 11011 F 41 1::a H W AY 12v TYPE axH►IO <br /> (Mailing Address) FORMS sS 9-29 <br /> NOTES -�- <br /> M TELA ,, GA 3 Sri <br /> (City,State,Zip Code) <br /> 2" - 4 tvoo <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may a submitted) <br /> 1•` N� <br /> N <br /> 9-0 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the E W side of 45F><-mO Ro,&c> approximately l.-4 feet/61P t o RTH <br /> of N I eA H W A-f 120 'Y AM rT-s. Av E, by performing the following work(description of work): <br /> 3�o" c.i ,P.P. IJ rrH 97k LI nJEaR- F. S <br /> C?F- k/ Re-=94to 10 Go u OT-r >Z to NT-vF-• 1�Js�Y <br /> Work will commence on or about 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 /> I ck- <br /> Signature of Applicant-Title Date <br /> E:1PUB-SV.WKWMTER.PSIENCROACHMENTPERMRAPPIICATION.DOC (OM8) <br />