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'. <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONI.Y <br />To:San Joaquin County <br />Department of Public Works <br />LH'lde:(J"Pd<2,S ~\'\e...I)('sl-n'ct <br />(Applicant Name) <br />\11 2.5 r-!--l W\I '2(p <br />(Mailing Address) <br />\...-i"cie.xl c..A qS 2.3G <br />(City,State,Zip Code) <br />C?0Vi )'?:,'t:,l-:'211 0 <br />(Area Code ..Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />JOB# <br />APN <br />EXP,DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS: <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the N/:s!f:jw side of \-\i(3'DWC:..'1 2("approximately 'D\'AllC:~'i'1 'Ret feel/mile . <br />of r.I ,by performing the following work (description of work): <br />'-\\edin-k De"'\\-~'\(lS-\-,-tve1-e.-. <br />\:::-',c .'(\"'"\\e..c.:\-\(--'n \J::H 2'0,Di".Is """sQ.0-\io\). <br />Work will commence on or about M 0,.'/']4-'0 t.'2..0\\II 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 />7JJh!/3 h.,--\/\lp <br />~~ant.lfiTe ~•'Date <br />E:IPUB-SV,WK\MASTER.PS\ENCROACH~AENT PERMIT APPLICATION.DOC (01108)