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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5/Zi I �3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7�a• 1 REF# <br /> Department of Public Works APN Cl # <br /> EXP.DATE 1.3 <br /> VALID I f0 DRIVEWAYS: <br /> (App' ant Name) STREET rY <br /> AREA Q AD <br /> L012.1 Bo I n P,6aC, TYPE <br /> (Ma'ing Address) FORMS <br /> NOTES <br /> \Wn ?4 m n I CA 014593 dick <br /> (City,State,Zip Code) o <br /> 2-44- <br /> (Area <br /> 44(Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Please, Cee, att6LCV1-e CL OLVLA W iV-\9 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HigLfwee;Mle <br /> ight-of-Way on <br /> the Uvesf side of WOddhr-i do approximately N6v <br /> of Mo 1 V—elurYt ne 6t. ,by performing the following work(description of work): <br /> DEC l ly\ieLL �g" x 26co" CCaUex eA irepeY'YYll+) , <br /> Work will commence on or about IS 2013 for approximately I D 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 /> 3 012D 13 <br /> Si nature of Ap icant-Title Date <br /> E:1PUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(01108) <br />