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01/16/2012 16:15 Alert-0-1-ite, Inc. (FAX)559 265 4549 P.0031003 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# //DSS REF# <br /> Department of Public Works APN CR# <br /> EXP,DATE <br /> VALID TO DRIVEWAYS. <br /> (Applicant Name) STREET -1t7_I00gQ =a• <br /> AREA Esc+gtor! QUAD ss <br /> 7 TYPE T�AiS41C e'e4" 90t- L�CyleAj ' <br /> (Mailing Address) FORMS <br /> 13 <br /> ;72— co, NOTES <br /> ,QQ-4-v (City,State,Yip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 112 3 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feettmile <br /> of by performing the following work(description of work): <br /> Work will commence on or about d'y1 . -/Z 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 Applicant-Title pate <br /> Ein,eev.�werars�,+cnawuHrrrmar�ru�nonnoo pwq <br />