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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLI=ASE(PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Jo2quin County JOB# NPau�(jp�2 c5 REF# <br /> Department of Public Works APN CR# _-- <br /> EXP.DATE 1- 2011— <br /> VALID_.� <br /> 3'' -� 3' �•�+_ _- ___�_ 7-2a-Za it TO DRIVEWAYS: <br /> (Applicant Nam€s) STREET \/OA <br /> AREA QUAD <br /> FS~ x,74?f3'lam' '3 C t)O. TYPE <br /> (Mailing Add ess) FORMS SS& 2 <br /> NOTES <br /> ?City,State,Zip Code) <br /> _ y <br /> (Area Code-Telephone Number) - <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, cons ruct and/or otherwise encroach on County Highway Right-of-Way on <br /> the C4;L-% _side of t-z" saCILf 124(j. approximately '- 11e)&I (;Xf7�, feeblw4le C-7- <br /> of by performing the following work(description of work): <br /> 2:r � <br /> A..� .G� <br /> Work will commeni e on or about.- r` 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 describegAove in accordance wipCpte rules and regulations of San Joaquin County and subject to inspection and approval. <br /> r X� <br /> Signature of Applicant-Title Date <br /> EPUB-SV.WKWASTEP..PSIEUCROAC:W Ni P_P.MIi APPUCATIOPI'.)0:: (071(8) <br />