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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 9-2-f OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7f-J REF # <br /> Department of Public Works APN CR # <br /> 0 EXP. DATE <br /> A1 r ! /o �_l y Oo-roAj VALID 91 "�L TO ��� DRIVEWAYS: <br /> (Applicant Name) STREET 40419A-)66 <br /> > AREA S�G.rcra�/ QUADCC- <br /> 900 <br /> C <br /> 2900 C L-'�5 /41 - n� TYPE <br /> (Mailing Address) , FORMS <br /> NOTE <br /> S�Gk ►>, 64 95210 <br /> (City, State, Zip Code) <br /> ,(Area Code - Telephone Number) <br /> Sketch Detailed plans may be submitted) <br /> hl O <br /> � <br /> _ dee /� cG� � � <br /> >Z <br /> w 0' CM <br /> = <br /> (X fox r Dz <br /> d <br /> N w Cto <br /> cr n <br /> xs C4 <br /> The undersigned hereby applies for permission to excavate;- construct and/or <br /> otherwise encroach on County 1-Fighway Right-of-Way on the --Gk3i side -of <br /> 6r,osc approximately 150fee /mile AkvNA <br /> of TUXIE06• by_performing the <br /> following work (description of work) : /HITT• To oAA!5l_ -,r RAID -rRrA CNF-RO -1 <br /> C-915W.AlS 7k= 40X TO Lets-Y-We L <br /> ToTAI. LfrAJK7-a Xs 1'77", L/ AM" OF SID4W Idl 6.1/LL QF ZeAbV&_D A/1/D <br /> RE fL-'D, 7_0rdt 7Z PY Sit. dl,s'PM r WILL 8E ,C'G-" "Ag To �,Nr-y TOTAL <br /> Work will commence on or about 4-15'- ZoaK for approximately <br /> 3B _ 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 /> FIZ <br /> Signature of p cant - Title Dat <br /> MASTER.PS\FEESCBDL (6/00) <br />