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., ps-I 100808 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5�2� �� � OFFICE USE ONLY <br /> To: San Joaquin County JOB# -/J3 REF# <br /> Department of Public Works APN 0 9 CR# <br /> EXP. DATE 1//�el-// <br /> Xl VALID 71 10 // /S DRIVEWAYS: <br /> (Applicant Name) STREET <br /> d� AREA 15�/a e e7ro%/QUAD A19 <br /> e✓�t�� � TYPE ��14 EI�lAGEJYIE✓ <br /> (Mailing Address) FORMS l �) <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> VV-PN--1 k � <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of 1:5, JM Voli approximately Z�SS" (f t/mile <br /> of &OA�dTni VV by performing the following work(description of work): <br /> Work will commence on or about w/j/1 for approximately D 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 /> c--�� — LZ er-%F-t C -3 ko ( kI <br /> Signature of Applicant-Title bate <br /> E:PUS-W.WKIMASTER.PSIENCROACHMENT PERMIT APPLICAl1ON.DOC (01108) <br />