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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date \\ Iftl i7 K OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000s'- REF# <br /> Department of Public Works APN CR# <br /> t EXP.DATE 2. 1 S•t?q <br /> VALID 112-10-018TO DRIVEWAYS: <br /> (Applicant Name) STREET W LcJLW&A> oa <br /> ( AREA -rip QUAD 'Sk1 <br /> TYPE -res x3CMI9C+,_ <br /> (Mailing Address) 1 FORMS <br /> Q11--\1 �S ss C-> NOTES <br /> (City, State,Zip Code) <br /> cl 2 G A S <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The dersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hig y Right-of-Way on <br /> the�--side of C-Y-i,�1) Ao approximately fee mile <br /> of , by performing the following work scription of work): <br /> Work will commence on or abo for approximately U 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 /> 9 d--- Ik ( to\1 (3 � <br /> Signature of Applicant-Title Date <br /> Y:'.FOFMS d TEMPLATE51ENCROAGHA&NT PERMIT APPLICATIONAoc 106%1 <br />