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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I - 12- I2 OFFICE USE ONLY <br /> To: San Joaquin County JOB# zo0� REF# <br /> Department of Public Works APNCR# <br /> EXP.DATE 2z <br /> a- <br /> N)LW 6141 i A12011I <br /> 11ullol IIZC VALID 1 t IZ TO 2 /2 DRIVEWAYS: <br /> (Applicant Ndtne) STREET ���,g,�` A <br /> AREA F iry� QUAD <br /> TYPEr�Fy' <br /> (Mailing Address) FORMS <br /> NOTES <br /> lCtt"1Y11f1�61 C)1 . �A <br /> (City,State,Zip Code) <br /> EFkcL - Fax- <br /> (140) fEk,-5-2.1 (ZQq) Y�o-10�5 I <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highww � Right-of-Way on <br /> the 1--cZ--t side of 111D approximately 1, 00o (feetknile <br /> of by performing the following work(description of work): <br /> Work will commenceor or a04LE 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 a Date <br /> E WUB.SV WKWAS'ER PSIENCROAC.MENT PERMIT AP.PUCATION USC (OMB) <br />