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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f /q— / 3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# AN! REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /3 <br /> ,r DRIVEWAYS: <br /> L GALT,' CLL/��. — 2i�1 �1! l7 % ��� VALID fo <br /> (A licant Name) STREET ,Q <br /> AREA QUAD <br /> TYPE I <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 I���TH side of -"5C-�t vim- / n� ��i�. approximately /�a 0 i fee- mile <br /> of ,by performing the following work(description of work): <br /> Work will commenceCon.or about 5 /3 ';211'r113 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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> � - 7 <br /> Signature of App-cant-Title' Date <br /> E:IPU&SV.WKIWIASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />