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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> S,PrAv: � un s VALID II 3 TO !/ 13 DRIVEWAYS: <br /> (Applicant Name) STREET luz RZAZIS <br /> AREA I Fbkl QUAD <br /> _ X g� TYPE SAL[=—r1�,AQ! 1 �11� <br /> (Mailing Address) FORMS �.-- <br /> ' NOTES <br /> rA QS c� y it <br /> 'F .3a al.Td <br /> (City,State,Zip Code) AAS <br /> (W9)15Cn-6&'01 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ck*i Loc k_. tMAbv�cAr _c,.pr'�c1 ikAxns kx--6 �,c��r�? w�:�cl, d�asal• .ds <br /> (IJA- oc) A,,5v�,,-) Ca�� <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 /> Vc� _ , <br /> �. l <br /> .d �' . <br /> r ` <br /> Work will commence on or about NtaA411,D1-j3. for approximately :L s 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 /> t <br /> ignature of Applicant-Title Date <br /> EIPUB•SV.WKUMSTERPSLeICROACHPXWPERFATAPPLICATION_DCC(01/08) <br />