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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (,2 h`A i CS OFFICE USE ONLY <br /> To: San Joaquin County JOB# Z7q='� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 <br /> VALID J 4!�d 0 DRIVEWAYS: <br /> (Applicant Name) STREET , <br /> AREA ' k r-,� QUAD J <br /> — <br /> 2307-3 C=_ \ > 1)2 TYPE ��, ni, A e� "_��, <br /> ailing Address) FORMS <br /> NOTES <br /> Sioc�� CJS- . �S2 1b <br /> (City, State, Zip Code) <br /> L- -)ti-1� � 0 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> S E P A-i TAcL--t r 1) ova v <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the sno- ( side of approximately (4IR2 smile <br /> Of GAL OF W t' A»JhA f _ by performing the following work(description of work): <br /> _XCA�(AcTF <br /> in---JAN RDW (I P`304$ 11,%)LF('?0",et-L3"-sc-3o") IN pletAt2 4 <br /> ' rat("0 co az 6n2 N ,1 Sr,wIc_�:Ct`7 NEM lit �—�� f' "[F�►�=� M <br /> Work will commence on or about `­7 i for approximately lS 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 /> Sign re of A icant-Title ��J 1 Date <br /> mow- `Tc 0 <br /> E:TUB-WWKkMASTER.PS\ENCROAC ENT PERMIT APPLICATION.DOC (01/08) <br />