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APPLICATION FOR ENCROACHMENT PERMIT . <br /> PLEASE PRINT• A: U if " <br /> Date ����7Jo2OU6 MAN Z 4iFR6:UQ6 ONLY <br /> To: San Joaquin County JO # T ( i- LLEW�) �' tEF # <br /> Department of Public Works APN _ CR # <br /> EXP DATE '(} 0(0 <br /> \�r,rfFc-/�zr VALID -31ZTO 4 DRIVEWAYS: <br /> (Applicant Name) STREET -Bien eM. * <br /> AREA ,LACY QUAD 5k� <br /> TYPE -ggs <br /> �� <br /> (Mailing Address) FORMS S- Lc�w ,e L9 <br /> NOTE <br /> S lorr,Tv-� Cc'• 9 5d o S, <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) �J <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County. Highway Right-of-Way-on the &s-7- 4-6tNe '> side..of <br /> l3;rd rld approximately eeee mile A;yrTh arN Lvo TA <br /> of 11a wctiy iZa by performing the <br /> following work (description of work) : 70 �n o <br /> 20 �C.�✓ :7'f �i�C�e ��.y ��2 .S%iov/c�$rS �'1i r�!' /Z7 �� e <br /> Work will commence on or about 3 fag /CC for approximately <br /> 4-1 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 /> Signature of Applicant - Title Date <br /> CSTeve.i k/iw"tr-' <br /> MASTER.PS\FRESCHDL (6/00) - <br />