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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> s _ <br /> Date �� g o ! 5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE i l4 <br /> ) �-I(:i H-T >)V I L- VALID �r lS TO DRIVEWAYS: <br /> (Applicant Name) STREE"F A51A&I21 "-P <br /> $!.�/ <br /> 2 5 _ r\J `FU(\ SAREA QUAD f� TYPE <br /> (Mailing Address) FORMS <br /> IV l'1?I�®� e ;�/? q's NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> L 9` J Sv ISI ( 7 _a: � -0P, . i2- E V/ E <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highw_a Right-of-Way on <br /> the6k1 lM- , -> _side of 13 YV-b l J R-b • a approximately � <br /> . PP Y— �--l( mile <br /> &Q-ON 67 IL-1 NT_ by performing the following work( escription of work): <br /> IAJPLEE i Ui/V iE A L.0/V G <br /> Work will commence on or about n � ' 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 descb6d'above in accordance with the ru'Os and regulations of Sari Joaquin County and subject to inspection and approval. <br /> f, <br /> if <br /> d f .4�f fi 7 <br /> S(giiWW6of Applicant-Title Date <br /> EPD&SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />