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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date C OFFICE USE ONLY <br /> To: San Joaquin County JOB# � .�`;a_.2� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 <br /> VALID 1;7 Pte, 2-- <br /> 0 5 �- DRIVEWAYS: <br /> (Applicant Name) STREET �, <br /> AREAat QUAD <br /> TYPE <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-1. side of A ho r, � �. �l�V)r��`�t�L� approximately. feet/mile <br /> of ti-,,; 1; .._V"_�- �,> _ ` by performing the following work(description of work): <br /> �yG <br /> 44Z c V ,r t_.rr7 c� ?G-Y r,t q) c4✓ ®--C- <br /> h,� <br /> r 7 _ <br /> Ca I✓it !1"'r s't r;� - 'r`LG-�i.T s n � ✓f fl0 L'- <br /> {2c/J <br /> Work will commence on or about "j� for approximately �Gdays. <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 /> s <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (01/08) <br />