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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> r i OFFICE USE ONLY <br /> To: San Joaquin County FAPN <br /> 2-o0 7O REF# <br /> Department of Public Works CR#L!7 /� T 2 DRIVEWAYS: <br /> (Applicant Name) DLE F+L(-D E oSEL4wr.1*AVE. <br /> AREA QUAD �tA <br /> I:�2 L I 0 TYPE ' Der N cj <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of <br /> of approximately feet/mile <br /> by performing the followingwor k de scn ption of work). <br /> ork): <br /> Ek'it:'</'T' GU1 i, '�,als `-+�v' ,�,� �.a#�'a` `.,I•i2.. Tftxt tlt ••,� <br /> 44�-_ <br /> Pi LI; <br /> -f / <br /> Work will commence-on about fi I for approximately 1 y da 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 /> 47 <br /> Si ature of Applicant-Title Date <br /> E:NUB-SV.WKWASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01/08) <br />