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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> / / <br /> Date 12 0 �f�` �% OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> ( y�'/e� �,�►tj C A4- S VALID YZ 12- TO DRIVEWAYS: <br /> (Applicant Name) STREET , AXW <br /> ¢yy� <br /> AREA AawyfbHUAD -15 <br /> Zvi Tiu Sao TYPE <br /> (Mailing Address) FORMS <br /> NOTES ' <br /> (City, 8tate,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 No1Lrm sa ode of Fz'>Ei�-J �, <br /> Cd-t ep V--p approximately feet/mile <br /> of , by performing the following work(description of work): <br /> 'R`� P a-g>v Cc)C �J p.Ncc ►-�� <br /> i by a Ll IC- f?-A-I int c A,,LS o i S <br /> TS 2 FArL 3%5 '� e )IL �4N p I�cL 1e-iy t l`1 C� <br /> Work will commence on or about t 2 t�� �. for approximately days. <br /> I, the undersi d,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work descri ed a ove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ` <br /> Signature of Applicant-Title Date <br /> EAPUB-SVWKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />