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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' 5'-6 -07 OFFICE USE ONLY <br /> To: San Joaquin County JOB# //p(,p _ REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> �1Y1 x'11 11'�,\-4 1'--_ VALID TO d DRIVEWAYS: <br /> (AppiicantAame) STREET <br /> ii <br /> ARE QUAD <br /> QUAD <br /> Rog. � Z 1 TYPE Ur-&ckSLt�t� <br /> (Mailing Address) FORMS ��' <br /> -r 1 <br /> NOTES <br /> -act d 0A -7 <br /> (City, State,Zip Code) <br /> i20q & 'F2-- -2-00 <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 HighNy Right-of-Way on <br /> the .56 ctt h side of :,a approximately /'X0-6 _ f� ile casf <br /> of I�c>ua se i~ by performing the following work(description of work): <br /> -0q1; e e nchouc-i► rrn Pe),-sr..uere Q <br /> atxd T1. r+,n S a e- -tfrY- p o S h t2. c t s <br /> [°D it n-c e of 8 i- t4f &J. Q iM d le t-se,-a e r-c b tz V, <br /> Work will commence on or about _I:r 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 /> SAfature of Applican -TifW Date <br /> Y VORMS d TEFAPLATES ERrPCACHMENT PEFVAT APPLICATiON.dac(OW06) <br />