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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB# ,� REF# <br /> APN CR# <br /> �f rLT M D V. EXP.DATE2_ ) I� <br /> VALID _ _G TO <br /> (Applicant Name) STREET DRIVEWAYS: <br /> M&A— e1 <br /> �-17�tb s?- , AREA �SkaC��v. QUAD <br /> TYPE �2���.al e $ Tye,6C tw <br /> (Mailing Address) FORMS S <br /> NOTES <br /> (City, Stat , Zip Code) <br /> Z©9� 4to( 2 t I <br /> (Area Code-Telephone Number) — <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,9onstruct d/or otherwise encroach on Count Hi <br /> the–h-�_side of > et�t,d S7- C Ani # Y 9 Right-of-Way on <br /> �.-- t-4A)►s 5-f— pproximately �oO y <br /> fee mile <br /> by performing the following work(description of work): <br /> l�►J��(v –We) LANG <br /> 1=,2ow� 3L L.n-�A <br /> /PGC S <br /> Work will commence on or about ),Q v /U, r11 <br /> for approximately <br /> days. <br /> or am qualified t <br /> I, the undersigned, certify that.l am the owner of the respective property, <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> o represent the owner and agree to do the <br /> " Signature of Applicant-Title — Z <br /> E]PUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01/08) Date <br />