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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I �r G� ZU � 3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE � 3 <br /> VALID ) TO 1J,3 DRIVEWAYS: <br /> (Applicant Name) STREET DUS <br /> Cr e G St TY <br /> V�'�)p ��I(� �( <br /> AREA <br /> AD .75 <br /> (Mailing Address) FORMS <br /> NOTES <br /> .0 1AAA9 <br /> (City,8tate,Zip Code) <br /> (Jv1 111 C Q �Lk VL ��V ,Z�� SZ (L <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ���'��11 l <br /> IMUV�-� W1G� 1� Ct'�C�/(;�--I ���`fiv�s vV1(� <br /> u� <br /> U►� '; C �c>>�� d <br /> loci <br /> The u9dersigned hereby applies for permission to excavate,yonstruct and/or otherwise encroach on County Highway Right-of-Way on <br /> the DO") side of S?\re.vcA t &v tk approximately feet/mile <br /> of , by perform'ng the fo lowing work(description of work): <br /> Uva VW61 61 f ��� Avo <br /> I J('u c'h�,G d 1/��"r l I 151 "r C-4/111/0 <br /> f�JL4 IW v \ <br /> Q ��� 1 f c/1/1 v�� �� 4�rn 1 c v) za CJ <br /> F Oft <br /> Work will commence on or about S 1 ;wc�u, I f 11WsA�. for approximately u h1�. 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 in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 12, /-201-3 <br /> Signatur of Applicant-Title Date <br /> E:IPU&SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />