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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12,1 i o 1 11 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3 REF# <br /> Department of Public WorksAPN CR# <br /> EXP.DATE 2--L _ 2ol <br /> VALID2150 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA S QUAD <br /> �,`�CTU �=�'f�►^'�-�'{�.I.r � TYPE <br /> Y <br /> (Mailing Address) FORMS 5 <br /> r( (( NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> &e-- CSACAt,,C St— <br /> �J <br /> The undersigned hereby applies for pe <br /> rmiss n to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of o0L A,11 P approximately I r-,-'l feet/mile L1 ir•-t <br /> Of gs�o� - by performing the following work(descri tion of work): <br /> rn IPA L)217irl <br /> Work will commence on or about Der 1'3 -7k,13 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 /> Signatu of Ap cant-Title (7��)-Q1 Ll U U Dat <br /> E IPUB-SVAKIMASTER.PSIE OACHMENT PERMIT APPIICATION.DOC (01/08) - `' � • •�tQ <br />