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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 11 l `Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> 06 C6 m wi(,t ri .4l-0A S VALID t0 (Z '// DRIVEWAYS: <br /> (Applicant Name) STREET C77 <br /> nn AREA QUAD WAW <br /> FIq 5 4 f n Q, Tc i oo TYPE T, iucff���,► <br /> (Mailing Address) FORMS <br /> r.0 \/ e Cr,( T6775-e NOTES <br /> (City,State,Zip Code) <br /> T Qsc3�7 t-rt <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> kt _ cl ,3E'vv i� ,� udd�`� t1 <br /> I <br /> 2� <br /> k � � w1 <br /> 40 .� f p <br /> 1-2 <br /> © Do q <br /> a �.;a %pt <br /> The andsig d hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> thel 2. side of oc-V-05 1 SiY-e-e-A- approximately 2�f' �cyv55 feet/mile <br /> of S v--e---e-er 2 2 0`3 ►, 1 e V1 C<gel' , by performing the following work(description of work): <br /> ,r-10—VNC-�X kc-v-oi5 S IV Q,I e- Cc)v✓-Cci4- ho�ie <br /> �k-tc, SeV -e Gf -.3+r��k �� c ±C3 V, <br /> r� <br /> 2- I -7 <br /> Work will commence on or about for approximately Kr 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 f Applicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACNMENTPERMIT APPLICATION.DOC (01/08) <br />