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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5— cF— /-Y OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> gam/J�14 EXP.DATE /S / <br /> `��'C'�' VALID fo S iS / DRIVEWAYS: <br /> (Applicant Name) STREET 46jAII9N 1eD Nuf,eD. <br /> .P AREA 15-46A40r/ QUAD S, ' <br /> TYPE GGo.SLa <br /> (Mailing Address) FORMS <br /> NOTES <br /> Aormwe AP, LP BHsr= AR C+eoss, <br /> (City,State,Zip Code) B96N!M M RD. e SAISAf-P-e9gZM <br /> Ti2A c.lcs '&E►n, 6056D Foe. r e i Q5 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> q7Ag1-1 <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 /> Work will commence on or about 5-19-14 _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 descr' ed a0ve in accordance ith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> EfPUE SVVWKWAMUtPMCROACH EHTPEFUTAPPUCA7*N.DOC Pl=) <br />