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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICH USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Deepartm�entt off Public Works <br /> ubblicWorks c Q / APH Cg # <br /> EXP. DATE G20 <br /> VALM 4-13--06 TO DRIVEWAYS: <br /> (Applicant Name) STREET MAP-54 IEZ + <br /> .\550 w .7LMO�T S�' lCYJ AREA d QUAD S + <br /> TYPE <br /> (Mailing Address) FORMS <br /> \,Sq� <br /> ly ao 3 NOTE 1 �- <br /> dC.C1o�1 �C� �- <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on. County.Highway Right-of-Way••oa•the a sid�..of <br /> approximately - feet/mile <br /> of r . . by'performing the <br /> following work (description of work) : <br /> W At lwrt_NZ_ ulk kN p M®RD <br /> S%R-M SlR.A =I Ck 131 <br /> GFi�.M ; <br /> Work will commence on or'about for approximately <br /> to O 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 /> [91.4THA.P3\PHBS®L (6/06 <br />