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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I ( � OFFICE USE ONLY <br /> To: San Joaquin County JOB# l(U 0 y S REF# <br /> Department of Public Works APN CR# <br /> _ n ` EXP. DATE I I -I S - <br /> ,E(�iE7�E1�Kt�1(r PrM,��� Ic�NTti' VALID i � TO - S- DRIVEWAYS: <br /> (Applicant'Name) STREET grA <br /> AREA L Uc e dUAD - <br /> 0 Cou R'v TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State, Zip Code) <br /> toot- <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -::,o �-A side of �--_P6T- L 3c Y Qty approximately ' cA;;, ti feet/mile ef�ST (E!Sr <br /> ofrpt , by performing the following work(description of work): <br /> �v r� �rS <br /> �= �i�T fk��c l►M:�C�ve�cr� �c�Rty� � vv rte, `-F'tr�l� <br /> Work will commence on or about C>c-To �z_ V_ 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 /> (- G � t /JL� <br /> gnatureicant-Title Dat A <br /> M:ICENTRALSERVICESICLERICALMB.SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />