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vcigv� n <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ...�.� <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB#APN REF# <br /> -f- I::- EXP.DATE CR# <br /> (Applicant Name) VALID , <br /> TO ! Z DRIVEWAYS: <br /> L STREET <br /> `J® I�a '[ � 9 j� (( AREA <br /> G� r,od <br /> U I ✓J . ---- _ QUAD <br /> (Mailing Address) TYPE �o� <br /> FORMS <br /> C— anCo`^Y CA 5a o NOTES <br /> (City,State,Zip Code) <br /> 0 ,'0-,2 '75 <br /> (Area Code-Telephone Number) _ <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned h greby applies for.,permission to excavate, construct and/or otherwise encroach on Count Highway the A-� S���7`t< side of t�1. 'i`C <br /> of d e r t` �J—�� d' !p o ''� approximately 300' y 9 way Right-of-Way on <br /> K b o t o Umile We. <br /> F4[( p a by performing the follow* g work(description of work): <br /> -E—o m a;►� o 17v\s ec- 5 res d e c es' <br /> ZN� <br /> ;-�- <br /> lot <br /> Work will commence on or about , <br /> for approximately <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 /> days. <br /> work described ain accordance with the rules d regulations of San Joaquin County and subject to inspection bode <br /> n '7 p and approval. <br /> ignature of A i ant-Title / / I <br /> E:PUB-"WK'MASTER.PSIENCROACiMENTPE;Mfi APPLICATION.DOC (01/08) ate <br />