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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2C5 I OFFICE USE ONLY <br /> To: San Joaquin County JOB# (� ..1 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE 64-20— 2013 <br /> QYl oG GtGt s� VALID -2°l -2e >ao 14 r2o - DRIVEWAYS: <br /> (Applicant Name) STREET (-�Nlkl nv\- <br /> SL <br /> CIA- <br /> AREA QUAD S <br /> C� S- S TYPE <br /> (MaiMg Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> to k-�- L'L <br /> (24�rea Code Telephone Number <br /> yo c S� <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission toP4061 <br /> cavat construct and/or otherwise encroach on County Highway Rig t-of-Way on <br /> tl, ' ,,� side approximately Z. 4 X16) feet/ a <br /> of ��-c� -� e�C"— , b performing the following work(description of work): <br /> Yp 9 9 ( p ) <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 /> 13 <br /> Signature of Applicant-fitle Date <br /> E:IPUB-SV.WKIMASTER.PS%ENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />