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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ��l�t�� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> �j'SPc(J C���- CAIJSU LT I/ a9—P VALID it• . TO JJ..I C,0?-- DRIVEWAYS: <br /> (Applicant Name) STREET 41 QY64a—" <br /> AREA 5TKK3 QUAD Lvl <br /> 301 k-t�-C,t�R R—D <br /> Sir-- /0-0 TYPE TJ G Cyl�iQp�--�J�F•�5 <br /> (Mailing Address) FORMS <br /> n � NOTES <br /> P• Nu-�-0 CID"cam ICA qSIP3V <br /> (City,State,Zip Code) <br /> (9kb) �)uA- a4m k32 <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 side of P JMu%cn4 So } 6e?-) Ho1-T approximately 1,WV fee mile FAST <br /> of GEt,CAoN-r ?I-. , by performing the following work(description of work): <br /> CLOsir4(-, f,,Ittgj:H &cw&-V Nop-T11 of 5 Ks AmAt) M i 'f 1-1E &oft dfs:a 1 <br /> Yea h= L.Ar-- ov ze,,1 woo a. t Pksf E L3eyiee-tts -TWE t-S W IyIE-9 2AMPS S WRA O-O O iD ftf-P� <br /> D �LTtoN t& 3 9-kN t <br /> -CV.At 1hC- N" of;�TQA*-D 6A,sT oN 5"C -IMP-+- tJ094•4 ons &92iQN apt ?LAW&. <br /> Work will commence on or about Wb\lEm6EY- q ,20001 for approximately 5 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 /> nuc--'-- rmT 101-7 10`� <br /> Signature icant.Title Date <br /> EIPUBSVWNNIABTER.PSIENCROACHMENTPERMfTAPPLICATION.DOC (01M8 <br />