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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ! 1( //'3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> 14p e X j5;t t��'f63-ktc,4 1 J/164 EXP. DATE <br /> VALID3 / fo 51 3 DRIVEWAYS: <br /> (Applicant Name) STREET Zo <br /> � TRPS 5fAf7q QUAD <br /> S (,A'Ja <br /> (Mailing Address) FORMS scs 1 W <br /> CSO IU /Z,✓ <br /> C19 c/51&70 NOTES <br /> (City,State,Zip Code) <br /> U) r5-1 -0 1-7 L( <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ��►5 cert. G.l��-C-.-c� <br /> The undersigned hereby applies forgrmission to qxcavate construct and/or otherwise encroach on County Highway Right-of-Wayn <br /> the 15a s f' side of S cif 5 >��cf approximately 0 - Ly� eet/ ile a�f� <br /> of e- i�7�L rs-taA ,% A s f�t�-, 134 /A,C�y performing the following work(description of work): <br /> bv L it �.4ro cA k4n ac hi uA e S 6'2e#-.c- -r e Gve,!!S A.-i d we o»,'�r,;, (,..t.f!S kcas-c.& <br /> dh 6 "• She 44 --d y' S/rc-t, <br /> Work will commence on or about Z !3 for approximately :5— 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 accordan with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i Y- , 3 <br /> Signature of Applicant-Title Date <br /> EVUB-SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOG (01/08) <br />