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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:: <br /> Date t of (--1-/ i4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> ( , U O EXP.DATE <br /> � A- - - <br /> VALID 7 l-/S TO - - DRIVEWAYS: <br /> (Applicant Name) STREET plew It 4r) <br /> AREA T�uT <br /> TYPE QUAD <br /> (Mailing Address) FORMS S <br /> NOTES <br /> (City,State,Zip Code) <br /> SAL- &04$ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S-ee q1 a'-N <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighwayRi ht-of-Way on <br /> the �� l�.osk side of ble»-e-k# f��d Q�e•wo�ti�„�approximately l .ce fee <br /> of 1-S 510 e oi✓•.•1 ��..� by performing the followin g work(description of work): <br /> waG�-haG✓�� AWeo.�lne-� <br /> a�•�- o�e� i:+1� •� e•-ooh-e�- �-rw,., ;+;a. +� b.� ,a 1� - <br /> Work will commence on or about 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 /> On-Ae-( QG CA,-(-o <br /> Signature of Applicant-Title Date <br /> ETUB-SV.WNIMASTER.PSIENCROACHNENTPMMTAPPLICATICN.000 (01/08) <br />