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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> DateD - f Z-01 Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3G�.Sl a REF# <br /> Department of Public Works APN CR# <br /> n EXP.DATE 3 1 13 <br /> VALID 2 13 0 3 1.3DRIVEWAYS: <br /> (Applicant Name) STREET 'e?145'e oo 3> <br /> AREA Farj QUAD <br /> :5r <br /> TYPE <br /> (Mailing Address) FORMSCK 0� ss�Jw <br /> NOTES <br /> (City,State,Zip Code) <br /> Lznq-) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) ,` <br /> 0c] <br /> I c�l a <br /> I <br /> (-(-NG A L_0''c."_ �`--- to c� <br /> N --- ----�5' - -- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the M nk-T- - side of f2- fz K 0 C) approximately E-5 ' feed W EST <br /> Of Eu CJr-R-11 A. &orf-\ _. � r�` , by performing the following work(description of work): <br /> r'OLFQR- Pic_ e-, SPLI c,E- <br /> - <br /> Work will commence on or about �Vkft 2 , 20 2----� for approximately 1 D days. <br /> 4-T3 I '1 FO&O FA A Fr-10, <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 /> 1 -z <br /> gnature of Applicant-Titre Date <br /> E:IPU&SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />