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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: / ; <br /> Date I V1ID ---A <br /> 1 j FJ OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN _ CR# <br /> ,1,�� EXP.DATE 3 /S/2 <br /> VALID 0 DRIVEWAYS: <br /> (Applicant Name) STREET ,QQ <br /> AREAq f <br /> (e <br /> O Qwc y- t(�6c r k PLGITYPE OUAD <br /> (Mailing Address) FORMS <br /> n ot 3.72-0 NOTES <br /> (Ci y,State,Zip Code) <br /> �t)4-7 - 5O (-7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> lbw <br /> The undersig ed hereby applies for permission X excavate,construct and/or otherwise encroa h on County Highway Right-of-Way on <br /> the�Q T side of rLA ISI appre to 4e4w#e <br /> of RaH PJ tD to52 Esc DYE, by performing he follow n�work(descri tion of wofk): <br /> i'l ( 1 2'� IJ ict�-I G S I�YI q t I ►n 6 �� <br /> /Y I ohvA, .11 <br /> Work will commence on or about-J 2-01-2— for approximately S - <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 /> \,Qm - Sr_ Gas ES+1 mafbr U/15,111 <br /> SignaWe o Applicant-Title bate <br /> E:IPUBSV.WKVMSTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />