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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> t <br /> Date ' <br /> � OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7300$2— REF# <br /> Department of Public Works APN <br /> CR# <br /> EXP. DATE <br /> VALID ' 0 <br /> (App cant Name) — /1 DRIVEWAYS: <br /> STREET o <br /> ` 5Z I L�\R �a 'i'or/ QUAD z.7 4EE <br /> AREA <br /> I�"i �- `�� TYPE <br /> (Mailing Address) FORMS H <br /> NOTES <br /> (City,Sta�Zi'pCo e) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> i � a <br /> The undeigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High ay <br /> the side ofapproximately Right-of-Way on <br /> �� Iry <br /> of 2 f e 6/mile <br /> by performing the following work(description of work): <br /> Work will commence on or about_ rJ f t 1� I t <br /> �J 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 /> T) lT'Li VG �'6 IC- <br /> Signature of Applicant-Title ---'Date <br /> e <br /> E:1PU&SV.WKWASTER PSIENCROACHMENT PERMIT APPLICATION DOC (01/08) <br />