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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Q[�"( �Z , �(jOq OFFICE USE ONLY <br /> To: San Joaquin County JOB# 10267 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE . .t <br /> D. VALID it.i .09 TO kZ.. k.p9 DRIVEWAYS: <br /> (Applicant Name) STREET AT6&pqy <br /> AREA r—,eAAckAl QUAD C <br /> O 1 1 f►. H ICI H WAY Mo TYPE TP-6x�Gktt?ty <br /> (Mailing Addres—s FORMS1,,L, <br /> NOTES <br /> M ANITE-c.A GA 9533(a <br /> (City, State,Zip Code) <br /> ?'+9 — '9"eo oep <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> C <br /> �I i%N4.Ac 44 MEWr d <br /> � NIa1-F AY 12a <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the r--/w sideof MuftP"y 24y,ciy approximately I,00n (e)mile W-OR-TH <br /> of H i ca H W, ,r 12.o Yasr--Nn rTr-- 44v-- by performing the following work(description of work): <br /> I�1�T,o.L.i..• �o L.�IV�AR. �T off- 412�11 GL„oss ly r- Ga P--L.'P <br /> f -a "ALY <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 /> Signature of Applicant-Title Date <br /> E:PUB-SV-WKWASTER.PSENCROACHMENT PERMIT APPLICATION.DOC (01M) <br />