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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date s.4')o:1JJ "MO"'"9 ,]..oUr <br />To:San Joaquin County <br />Department of Public Works <br />CALI r-:..c){2..!UJA viATER.c5Ef?..OIQ.E,(Applicanl Name) <br />!I.oOa.E I--AFA'i EirE ST <br />(Mailing Address) <br />-.sTO ~'t-TON (2J1 qS C).DS <br />(City,State,Zip Code)'~g~if LDY -~3/1~(Area Code0 telephone NumlJer) <br />Sketch (Detailed plans may be submilled) <br />JOB# <br />APN <br />EXP.DATE <br />,VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />730077 <br />OFFICE USE aNI.Y <br />REF # <br />CR# <br />DRIVEWAYS: <br />The undersigned hereby applies for Perrnission to excavate,construct andlor othelWise encroach,on County High.a Right-ot-Way'on <br />the v,.)-Y2+side of bY'Q'r)Ich approximately fee ile I\lcrH.., <br />of ,(I ho.A.Q .u.:v",by performing the following work (escription of worl(): <br />I , <br />Wod(will commence on or about ~I (p for approximately days.(5 I 1ft> <br />I,the undersigned,certify that I am the owner of the respective pro erty,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 />~~a16-a~sCb16SignatureofApplicanl-Tille <br />Ik\CEmRAlSERVlCES\ClB<ICAl.\PUB-.SV.WK\lMSTERf'S\ENCROACH~1ENTPERMIT APPlJOA110ltOOC (O~113)