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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date g / j s %8 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1f ;,- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> tm00 ' (Chckrl,t S+N�N��c� VALID TO feb DRIVEWAYS: <br /> ' (Applicant Name) STREET <br /> AREA �.�p�i QUAD <br /> TYPE log ?' <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State, Zip Code) <br /> Co-1,09 ) S33- 6-706 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> I �,�p�ca c I✓t',� �-`, <br /> �' �0 )� <br /> 0 <br /> ---- __ -- <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of ,T Davis R'o{ approximately 50 fee04�{� <br /> of—ko,41 k,, nan Lwr. by performing the following work(description of work): <br /> 11%X+01f/ ot.'pmtfe. Chwxr" 0ri'011i X1,1 &P, <br /> �1- <br /> �1 ffir. Ctosus'P, bn -f',. j_ A0, R-OCtd W.A Lo-,/ -,r"g ioCR:�ael IS <br /> 00-511 J C`�ftr-An.; R/W <br /> Work will commence on or about '5�t I s 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 /> �"�• (,.��'t SZ`�U�Ce S sti'�'J,r��.e�Z.r S�151 U <br /> Signature of Applicant-Title bate <br /> E:IPUB&SV.WKIMASTER.PStENCROACHMENT PERMIT APPLICATION.DOC(01/08) <br />