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01/1'7/2011 11:58 14084611470 PAGE 02/06 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> 23�fgZ- <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID /I T 0 DRIVEWAYS- <br /> X"7 plic t Name)/ STREET G <br /> c � 'ry/if .� ho�w(or–S AREA a QUAD Lam_ x <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> e <br /> ?? (C %te,Zip <br /> /C e) <br /> (Area Code,Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The u der igned hereby applies for permission to excavate,c nstr pt and/or otherwise encroach on County Highway Right-of-Way on <br /> the s- si of o _approximately_L:2'7,_ 0-00' feethoile AF.6 <br /> of by performing the following work(description of work): <br /> r rte <br /> Work will commence on or about for approximately da <br /> /-"-/ cd o oar` 07 <br /> I,the undersigned,certify that 1 am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described a in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signat of Applfcant-Title Date <br /> E:WUB.$v. @AtetFRDSExGgpAfva4W PERT AppLrAWNDW(0146) <br />