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APPLICATION FOR ENCROACI[SENT PERMIT <br /> PLEASE PRINT: <br /> Date I I f(3/ OFFICE USE ONLY <br /> To: San Joaquin County JOB # /loos REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE ti 14o--4X. <br /> �"�VS� T 11-Sw `r Ca• VALID «45-,6(. TO #-/L-UCo DRIVEWAYS: <br /> (Applicant Name) STREET <br /> M .. <br /> AREA DS C LQUAD 56 <br /> ZO S• l3 �T , TYPE 'TLsAA 120 4 n <br /> (Mailing Address) FORMS <br /> NOTE <br /> sT�TO�I �C�Oa • 9SZd� <br /> (City, State, Zip Code) <br /> C2o� X45—�38�' <br /> (Area Code - Telephone Number) <br /> Sketch (Detailedplans may be submitted) <br /> 1�8 V'CJJ �Z G�aSkCe -(-v �c4 secoe J .Qdi I D -i-RAcIL . "q�T�41t�S <br /> J;,x- -pe4�.p Ca+'�xl,e�� dt4&%.w a,-p-tJ s%.3v%2 - b� Ale r-F--o-La-►C . <br /> CW.cR-leF -Ib TAI �RoM r�ov� �tR. 15,?.0010 C 18oa ori oz�i,ry <br /> rnti. �ove�iw l(„2�oc� ,lZoaa -b�e re- 1+,j �I9F <br /> The undersigned hereby applies for permission to .excavate, construct-and/or <br /> otherwise- encroach on County Highway Right-of-Way-on-the We s.+ - side_of (n� <br /> o� T2.ea� approximately ►oo smile fir. &Q14d T,P <br /> bx pe form'ng the . <br /> followin wor (des ription of work) : •( �Y2e CrOS Sl L_L <br /> Ak '11 I C ZOU b LIP 1 <br /> All e - <br /> Work will commence on or about Mayem,6A Imo+ (goo for approximately <br /> LtA s <br /> 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 /> /! 0 <br /> S gnature of Applicant�- Title3 Date <br /> MASTBR.PS\HBSS®L (6/00) <br />