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Sep 21 12 10:10a CVIN 5594426047 <br /> p.2 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �-/ 2� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN <br /> EXP.DATE CR# <br /> — _ VALID TO ,y DRIVEWAYS: <br /> (Applicant Name) STREET 0 ,p E AASd! if/ L <br /> AREA QUAD _N✓ <br /> D TYPE 'min ASG Yt 8ER 1 n�a fie► rT <br /> (Mailing Addr s) FORMS <br /> C1 NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted)2F --- 0 �a <br /> VJ(/E t02(,-o4 <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 approximately feet/mile <br /> o� <br /> k til - by Perfofming the folloWig work(description ofork): <br /> Work will commence on or about fora approximately y 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 escribed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ilk <br /> I Signature of Applicant-Title ., Date <br /> FIpUC-SV.N.'YVAA$7EF,.p'i[I{GI?01.(;!:MEt{T Pc'RAgT APVLIGP,TIGt{.00C Iota) <br />