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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: I <br /> Date f Q ! OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE L[- I 2011 <br /> j I j)t✓! ✓ VALID 16,21_201J TO 00- DRIVEWAYS: <br /> (Appli nt Name) STREET Mn're_yti,G 2 <br /> ,�/� j� ]� AREA �C�CKA0V\ QUAD �, C <br /> , (oo l "Olrc " 7 (�Y� ()� tl t �C TYPE <br /> (� 1 (Maili g Address) FORMS <br /> J�GI'{ ►'1 , 06 NOTES <br /> �p (City,5tate,Zip Code) <br /> ( <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) / <br /> 7 'I, (Cr 4V"d='k2ton/at"/6') <br /> The undersi ned hereby applies f r permissi to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the e' side of Mel, apfftxtffa e y feeV4 ile-_ <br /> 'Rf tMb pe orming the folio ingrwork(description of work): <br /> fh n ': 7 r' cosi`✓ �� <br /> Os� "" r "a <br /> Work will commence on or about 0for 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 des5ibed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> pro;e, ge, <br /> Signatur Applicant-Title ate <br /> EVUB-SV.WKWMST SIENCROACRMEN7 PERMITAPPLICATION.DOC (01108) <br />