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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12 zt 7Z/6 OFFICE USE ONLY <br /> To: San Joaquin County JOB# l/QD(jj' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 1 <br /> C4 (e Sti Pcogq✓1 VALID 2,11 T6 2 DRIVEWAYS: <br /> (Applicant Name) STREET �$� D, <br /> AREA QQ AD <br /> V 4eTYPE L o ✓ C �� <br /> (Mailing Address)( FORMS l/ <br /> NOTES <br /> Fr�.���, �.uy'',✓J , C �531 <br /> (City, State,Zip Code) <br /> (;a9) 1145 &D5 <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 side of approximately feet/mile <br /> of , by performing the following work(description of work): <br /> �'zp <br /> Work will commence on or about for approximately AW J0:3 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 /> Z----- 12 ZQ /lam <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACHMENTPERMIT APPUCATION.DOC (01108) <br />