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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# �'2� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2 1 — Zc>l Z <br /> 441C iC �, GT,eI _ VALID { 2- 1 2ol1TO 2-1-2c>12_ DRIVEWAYS: <br /> (Applicant Name) STREET r2 <br /> A,4 <br /> AREA Vre_V'C\nCawUAD 5r <br /> pp <br /> r']5C S ml H_wA-TE(L �19A,4 TYPE T, 2�n V- l <br /> (Mailing Address) FORMS SS W 2 R <br /> n NOTES <br /> (City, State,Zip Code) <br /> ze-/988 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> P/A,Js. <br /> PM - 3b Ssy��9 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right- Way on <br /> the tnN side of e_'. pgf6A C MN��,4,d approximately 6.0 Q� ee ile <br /> of C kAt( s- , by performing the following work(description of work): <br /> /1EloTe �" ST�E� 6,�s Zrla�.� G f/wy 99 <br /> Work will commence on or about Fig// a0// -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 /> Signature of App cant-Title Date <br /> E'IPUBSV.WNW✓+STER.PSIENCROACHMENT PERMIT APPLICATION DOC (01/08) <br />