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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 51, 7116) OFFICE USE ONLY <br /> To: San Joaquin County JOB# D�'Z_ REF# _ <br /> Department of Public Works APN _ CR# <br /> 6 EXP. DATE t i i <br /> VALID b Co 10 0 1 ry kk DRIVEWAYS: <br /> (Applicanntj,Name) //,� STREET (�'RT�D6 Cdr; --- <br /> — �r �2 -'�� (J�-r j AREA ST -Kral 1 QUAD IFS <br /> aa <br /> TYPE 'F�s <br /> (Mailing Address) FORMS Ay e-2- <br /> � +� ekq}— -NOTES <br /> (( ity,State,Zip Cobe) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitte ) t <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the IL-5 Ir side of �_ . -rr.f _. .� approximately. C2v feet/mile <br /> p� g f C if - - by performing the following work(description of work): <br /> Worl;will commence on or about— J for approximately <br /> _ 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 /> r ture of Applicant <br /> -Title Date <br /> E TUBSVWKWSTER.PS�ENCROACRMENT PERMIT A PLICATION DOC (01/08) <br />