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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -Z 0 OFFICE USE ONLY <br /> To: San Joaquin County JOB #�3G�b'�-(�.3 REF # <br /> Department of Public Works APN CR # <br /> —/ 7 <br /> EXP. DATE 3.15- W <br /> !n 7 / / �' Joh �VP��°n VALID D TO 4-IS-(o DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ l l AREA QU _ <br /> Z ®O L Mi�� f�� vG/C71�'n TYPE f�✓ + <br /> (Mailing Address) FORMS <br /> / ,r NOTE <br /> (City, State, Zip Code) <br /> 2 o 7 - y?41 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the - es-� side of <br /> O r o approximately r3 feet/mile Akn4 <br /> of Secy ;Dl Lj.�-- by perform <br /> inj� the <br /> following work (description of work) : 477- 0 = 4e� r,�, T� vrc <br /> Cae � f%cc X�� !�n�K/ter, Tine in Pf *nd ab r Coad /sA ,-&--. Jwory<' <br /> �Oicd Tlir(d e v.!/ /Jof �c ia+/—nilee/ Or- J,-y11ie2 /J+// <br /> �+il C�x;i oQP <br /> work will commence or_ or about 7-"4 lD 2010 for approximately <br /> K0 days . <br /> I, the undersigned certify that i am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Appficant - Title // Date <br /> 056� o,,4,4on _ <br />