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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date milt t L OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> -t 6J V► A V14 NOA vle �'�'� EXP.DATE Z <br /> v VALID Td DRIVEWAYS: <br /> (Applicant Name) STREET a. <br /> 1 U�&Vti NvZ AREA QUAD --?4) <br /> TYPE ,�Oig1/1C�s ,i,�tG'Sryy��LJf� <br /> (Mailing Address) FORMS L✓ <br /> Ty ( CA, ��(� +'�� NOTES <br /> J (City,State,Zip Code) <br /> ja OS) r9t! 0 - tic,-7Z <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies forppermi sion to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> th&QA side of '-2 rMA -vs Hyl Q�AA approximately f'J— re mile <br /> of AVle Ci'SQ by performing the following work(description of work): <br /> �(0 v1 S Gywl tn�v�, �� tikl� +r�r.� o►w;�n�t Jv� myyt� r k fat V t,; <br /> 2 <br /> Work will commence on or aboutk'i 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 de cribed ab9ve 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:PUMVAWKIMASTERPSIENCROACHMENT PERMIT APPLICATION.DDC(01/09) <br />