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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date '-� f )� I, � <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works APN JOB# -�d�__t REF# I <br /> CR# �— <br /> EXP.DATE <br /> _ L <br /> (Applicant Name) VALID €i 9 TO Z g 16 DRIVEWAYS: <br /> STREET , !-L <br /> TYPE QUA __.____- <br /> (Mailing Address) ,q� <br /> FORMS '�".�- <br /> C) NOTES ' -----_ <br /> (City,State,Zip Code) <br /> (Area Code Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S9 <br /> f <br /> If <br /> 71 2 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach <br /> the side of <br /> of - ----���`� �-�" a on County Highway Right-of-Way on <br /> T approximately ��; fee mile <br /> Ci _ y performing the following work(description of <br /> Work will commence on or about_ <br /> for approximately <br /> I, the undersigned,certify that I amthe owner of the respective property,or am qualified days. <br /> q a dounty and subject <br /> to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin C ' <br /> lect to inspection and approval. <br /> I T .1 <br /> Signatufe of Applicant Title IE.N= P2cx--N <br /> E:WUE,SV.W.KWSTEpp"ENCRCFCHM",,PERMITpppLJCaTION.COCDate <br /> (J1rQj <br />