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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# �i�J" REF# _ <br /> Department of Public Works APN CR# _ <br /> l c,r r SU,, EXP.DATE <br /> i� 9.05J.p8 <br /> VALID 9./.OIS TO •/$' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 6/.. l QUAD <br /> p. TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State, Zip Code) <br /> (Area Code-Telephone Number) -- <br /> Sketch(Detailed plans may be submitted) A albx�i a + J �c . .,,:,, *. 1��;:r� -,ra61� WO <br /> 4 <br /> f <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ;j_ side of ., approximately <br /> of by performing the following work (description of work): <br /> yr .. ... ....+:,fid Yf 0_ a.r <br /> York will commence on or about for approximately 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 /> Signature of Applicant-Title Date <br /> E:IPU8-SVWKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />