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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12-1 12--- OFFICE USE ONLY <br /> To: San Joaquin County JOB# ��j,� `� REF# <br /> Department of Public Works APN CR# <br /> _ <br /> ky, <br /> EXP.DATEa C� l 0"n VALID 411113 tO 6,1111-9 DRIVEWAYS: <br /> (Applicant Name) STREET 49 <br /> AREAQUAD <br /> TYPE 1 <br /> -� �0 3 <br /> (Mailing Address) FORMS h1 <br /> (',,� NOTES <br /> � <br /> 1 ) ` 1 C O ) <br /> (City,State,Zip Code) oma- d/ tin to <br /> n � -(06 0 2 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> lb <br /> Thendersigned hereby applies for permission to exc vate,construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the 0 r4`� side of approximately SQQ feet/mile moo—, <br /> of S CkADr, ` S G0, on , by performing the following work(description of work): <br /> C CO <br /> Work will commence on or about 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 /> Y <br /> Di <br /> Signature of Applicant-Title Date <br /> E:1PU&SV.WKIMASTER.PSIENCROACNMENTPERMIT APPLICATION.DOC(01/08) <br />