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APPLICATION FOR ENCROACHENT PERF <br /> PLEASE PRINT: <br /> Date o <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works APN REF# <br /> CR# <br /> &C7/' .f, EXP.DATE <br /> VALID t TO tj DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ,gyp <br /> S�2_ 5 7 -"S-z- AREA QUAD <br /> TYPE -- --— <br /> (Mailing Address) S <br /> FORMS <br /> k t NOTES <br /> (City, State,Zip Code) <br /> YVe <br /> (Area Code-Telephone Number) Z <br /> Sketch(Detailed plans may be submitted) <br /> �1 �} _j <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach o County Highway -of-Way the � _side of d,= {' yon <br /> of <br /> —L4" approximately <br /> sr7',N <br /> by Performing the following work(desdr ion of work): <br /> r <br /> v <br /> Work will commence on or about <br /> for approximately days. <br /> I, the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner andree todothe <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title <br /> Date <br /> E'WUB,SV.WKIMASTERPSIENCROACHMEM PERMIT APPLICATION POC (07108) <br />