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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />OFFICE USE ONLY <br />JOB#110005'REF# <br />APN CR# <br />EXP.DATE 'I-tHe- <br />VALID "}-2.H6 TO q-/>-{G DRIVEWAYS: <br />STREET R,I,gw,.,o ed.• <br />AREA (weldon QUAD tlW • <br />TYPE ?51t1ll • <br />FORMS &'8 <br />NOTES <br />To:San Joaquin County <br />Department of Public Works <br />~I",\nQidv-ke, <br />(APPiicant Name) <br />200'4-v~4,'r-ro'''''''!lvi-d,$"'il![t'o(Mailing Address) <br />C;bzck:h1",M 4 S-2-0 & <br />(City,State,Zip Code) <br />(-2.0'1)'?'1i'-11/"(> <br />(Area Code.Telephone Number) <br />Date <br />Sketch (Detailed plans may be submitted) <br />G?e Ovt'hteted P 4,,1 <br />tat I, <br />The undersigned hereby applies for permission to excavate,construct and/or othelWise encroach on County Highway Right-of-Way on <br />the IJQ."t-side of ~e i)l"nw \!g••A 3JlW6xiliiBlely feeb'Fllile _ <br />~c;lo~tW.P.!1n'd-1&~'ih C"r ',ovo -fr i.1.wy.Jj ,by perfo~ing the following work (description of work): <br />-llj'.,6~r,.•,",'~-.'to J".'~.r J .•1c-,c.....:11 ~1"lId &.r (#r <br />1,.t.""",11..(4 1'f•...l •..••'1'A:tI bai"col;II b.<.b.,4tf,'li&l .v/e..t••"'.•...'r""r <br />c.vLir-;ltc!Hie,'':ts1!!Q CpOCcl...+l.';"4 LVt:t:;,",,,,ed wo",k pillO <br />Work will commence on or about 0 ICC l,,)for approximately 2.days.~- <br />I,the undersigned,certify that I am the owner of the respective property.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 />Date <br />E;1PlJB-SV.WK"lW.ST£R~£NT PEll:UIT ,o..t'PUCATlONOOC (Ot<l6)