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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z_ 12 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> CN VALID 2 Zo )2 TO 3 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 5T4,,?,7Z lQUAD <br /> TYPE Qa{ j <br /> (Mailing Address) FORMS �J <br /> NOTES <br /> ,rs — 7),!Q, - <br /> (City, State,Zip Code) <br /> q3 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 51 F 7, <br /> ( ova) u0cl - ODD a- �0.� ��w � \ � <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the!� rrl-- side of approximately feet/mile <br /> of , by performing the following work(description of work): <br /> \),D-+1 c J t a rni n� c�- t+{-�i►' c ,1�,� ; . Us 1\ w 1 a l/ i 3�t -rrn-s <br /> -;✓zti-� <br /> Work will commence on or about 2 z o 6 L for approximately S N!15 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 /> igriature of Applicant-Title Date <br /> E:IPUS-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/00) <br />