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APPILICATION FOR ENCROACHMENT PERMIT . <br /> PLEASE PRINT: SAN J 0;,G U I td G U N T Y <br /> 03 <br /> Date 6 OFFICE USE ONLY <br /> DEPT. OF PUBLIC WORKS <br /> To: San Joaquin County JOB# REF# <br /> Department.of Public Works APN CR# <br /> EXP.DATE //-0 Z Lo/2 <br /> t, VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET rR4n/1,e4A/ 4vevur <br /> ?M ^�-, AREA C C QUAD A/W <br /> O ^ IAV l w' ,VJP- Do, �r219O TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) 1 <br /> 9 tjcl— - �q%3 <br /> (Area Code-Telephone Number) <br /> Sket h(Detailed plans may be sub fled) <br /> C(� <br /> C <br /> t J <br /> �--- <br /> weR <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwy Right-of-Way gn <br /> theu Z side of approximately Ift rk e mile <br /> of s by performing the following work(description of work): <br /> Work will commence on or about 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 /> 31 �-- <br /> i <br /> 16— <br /> n r of Ap nt-Title Date <br /> E:1PU& KIMASTER.PS¢N ACNMENT PERMIT APPLICATION.000 (01/08) <br /> _t. <br />