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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date #/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Lke `Z VALID TO _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD _ <br /> 1-1 1 N\u .ti S�°et✓�" TYPE <br /> (Mailing Address) FORMS _ <br /> NOTES <br /> cA 95326 <br /> (City,State,Zip Code) <br /> 3ce - 9 �FS� — <br /> (Area Code-Telephone Number) —� <br /> Sketch(Detailed plans may be submitted) 1 <br /> Qy"`� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High�way`,,R�ight-of-Way on <br /> the ��S _side of��a e++, Lgh approximately is ?Anile so <br /> of R ob— a�e �ve✓��— by performinp'k <br /> following work(description of work): <br /> ct6Va"'c;r ova d�a,..e }er So \ b •r a oioo ee+ Wb� <br /> +a zyvr >o�2 codec-K' C, WC' (e- 71•-.k- 1Ov."Ncl <br /> Vim_ rn^^ e <br /> s�r�-t ua tt �� (-:��1,ked w: a� as9!^Glf �atcl,. <br /> Work will commence on or about IAk pfor approximately a 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 /> Signature f Ap#icant-Title Date <br /> E:'PUB-SV WKNMSTEP.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />