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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1170106 _ _ OFFICE USE ONLY <br /> To: San. Joaquin County JOB REF# 13 0 5 2—' <br /> Department of Public Works PpN CR n <br /> EXP. DA E —} 1 O _ <br /> _ VALID Zb1O6 TO q JS fit, DRIVEWAYS: <br /> (Applicant Name) STREET _EJL-1 <br /> C3 V�Q eD D. _ <br /> AP.EA LO n I QUAD -- -1 E <br /> �( (D w4P5 - L,awl,! TYPE LL MIDLE _ — <br /> (Mailing Address) FORMS <br /> NOTE <br /> �o r.4 <br /> (City, State, Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherw'se encroach on County Highway Right-of-Way on the CA '5 � side of <br /> 1eGK6r1q13,4 A?9approximately 13 0 feet/mile n ,_,__4 <br /> of Kp 6Liiv 4k, j ,,4.pt,/ C o by pelrforming the i <br /> following work_ (description of work): NO/Loo <br /> O f/ /'h 40 --14,01'rt 41,1� (:5A 5 S' C <br /> I <br /> - I <br /> work will commence on or about 2 /� �___ for approximately <br /> 11Pl� days <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Az� <br /> S�y—a— =cant - ��tla Zat_ <br /> SYN - - <br /> MASTER.YS•,.FEESCSL (6/00) RETURN PERMITS TO: <br /> PG&E <br /> JOB PROCESSING DESK - BLD 1 <br /> 4040 WEST LANE <br /> cTnrKTr)N (-A 95204 <br />