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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date } ' �IC;,� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1/0.0©,5— _ REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE / !o <br /> c_ — <br /> �r',' VALID23 10 0 _ DRIVEWAYS: <br /> (Apple nt Name) STREET ZIA& <br /> AREA Me"r&-A QUAD <br /> TYPE <br /> (Mailing Add ess FORMS <br /> NOTES <br /> _rig�'i,✓- C t tG'1 9 L fir' i: yy <br /> (City,^State,Zip Code) <br /> (Area Code-Telephone Number) <br /> J09- s- . v&I6 <br /> Sketch(Detailed plans may be submitted) <br /> y <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High Right-of-Way on <br /> the_ side of approximately /'v fee ile <br /> ofAd%�— by performing the following work(description of work): <br /> Work will commence on or about 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 ac dance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> zz <br /> e of Applicant-Title Date <br /> EIPU&SV WNIMASTER.PSENCROACHMENT PERMIT APPLICA310N.DOC (DIM) <br />