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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date t` � �-i I V-2— _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# x/005- REF# <br /> Department of Public Works APN CR# <br /> I I EXP.DATE � 7 J�- <br /> l <br /> ✓�3o `J VALID 7 0 7i DRIVEWAYS: <br /> (Apppli�cant Name) STREET l aLT <br /> AREA S-�c.l�'6N QUAD <br /> r TYPE 'c gyp_ �2o+AD Cl o u(26 <br /> (Mailing Address) FORMS <br /> S q57 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 approximately feet/mile <br /> of ��t In, by performing the following work(description of work): <br /> Work will commence on or about ?CNCMVX r ka , 2012 441—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 /> rk described abov in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sig re o Applicant'-Title Ca�Y ,.�t-vr Date <br /> E:IPI10-SV.WKVv1ASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />