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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB#APN OO kDS REF# <br /> � <br /> XP.DATE S- CR# <br /> � '201 <br /> (Applicant Name VALID ,S=22_tall TO <br /> ) STREET F-i DRIVEWAYS: <br /> � 5. __ � ,�1�r�/LI�j� \ --� AREA <br /> TYPE QUAD FORMS <br /> (Mailing Address) �v <br /> c-'C1'E'(--(�-'1='� C;� ' 562- >7 NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> L <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise <br /> the side of E�- �,� � ) <br /> encroach on County HigVwa Right-of-Wa on <br /> a proximately /C-1�' Y <br /> ile <br /> by performing the following work(description of work): <br /> %r j <br /> Work will commence on or-about y ZZ <br /> for approximately OiZ <br /> I, the undersigned,certify that I am theowner of the respective property, or am qualified to represent thedays. <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> \ Si0a ure of Applicant-Title C-Ar ` `� <br /> E.W II WxuWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01/08) Date <br />