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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I I- ► 12j OFFICE USE ONLY <br /> To: San Joaquin County JOB# I t d , o S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 2-17/13 <br /> L I v O ew) PG- 12 C INk-ty\+ n o t'"``A OLC . VALID 12 TO 7/t 3_ DRIVEWAYS: <br /> (Applicant Name) STREET St <br /> V1c-,-,e,—vs�-/ <br /> AREA QUAD _ - 'E <br /> r?D.4-0K "� TYPE Tome Poad Ctoiuer <br /> (Mailing Address) FORMS SS/L✓w <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 6V <br /> Z <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the •f—vt �,ef�-LAtitt-5 LW- Pr�N, c,,. r approximately feet/mile <br /> of by performing the following work(description of work): <br /> t^I Uy99t / 0 N 14A-,, S-t- VV\ all D�CA-'lM <br /> T-Y O'vv� �J O inn = � a �D 2 t}D t-\YD�\4 (^.E'C.ECS2�4Ti t3�1 <br /> Tittr LIN vin tMy" 1 T�/ <br /> Work will commence on or about 1 Ct-/viscy2 :7 , Zzc r for approximately 3' -L <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 /> Signature of Applicant-Title pate <br /> M:10ENTRALSERVICESCLEPoCAL1PUaSV.WIMMSTERPS1ENCROACHMENT PERMIT APPLICATION.DOC(09113) <br />