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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -At /i�/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# y WP?�p( REF# <br /> Department of Public Works APN CR# <br /> 6001 Co��S�2yc,�rc�lJ EXP.DATE /L- <br /> VALID T DRIVEWAYS: <br /> (Applicant Name) STREET <br /> P O <br /> BOX is/ AREA � QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> -57,000-01k) . (-A 9 Jo I NOTES <br /> (City,State,Zip C <br /> IR7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed"plans may be submitted) <br /> PLAN 6 14 6,41 y SUdill <br /> Cox �.9 I-vl) <br /> The undersigned hereby applies forermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wayon <br /> the_ /A LL s4de-of S: approximately a 000 feetImile ANON <br /> of atio a6A91 j& __ 0 WKPASS by performing the following work(description of work): <br /> FULL 20 o S -f TdAJ fALA " L 1^1ce�T f O11i9/ry,� Gni fr^�uc �c�� <br /> Work will commence on or aboutfor approximately � oR1C�r,�` <br /> 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 Date <br /> E:IPUBSV.WKWMTERPSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />