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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: //�� <br /> Date �;),� , Zy i OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> jf II EXP.DATE 7 <br /> VALID -&,,(14t11 tO / / DRIVEWAYS: <br /> (Applicant Name) STREET R-D, <br /> AREA QUAD KF <br /> TYPE21 <br /> (MailingAddress) FORMS <br /> SToc 1A 1', 4 . 95,121O ,N NOTES <br /> (City, State,Zip Code) <br /> � <br /> a - <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �_ i-�W �� fid. S�/��► /?/ <br /> Are,, J �1� <br /> �:(.A Ill/off l ---� <br /> The n ersi ned hereby applies for perm& ion to cavate, construct and/or otherwise encro ch on County Highwa Right-of-Way on <br /> the d side Qf E �� .j f f� approximately ee ile Egs�� <br /> of 0 1 by perfQ ming thework( e criptjon of wo/k): <br /> 1 .f �ollow!Vg <br /> fz <br /> ee �n1I 1 �r' r'E"ce or> J <br /> c s Lao <br /> Work will commence on or about_� v.ue��o 1l for approximately day/. <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 /> ` � [?CSC?✓ <br /> Sign of Applicant-Title Date <br /> E TUB SV WK ER 1S11BCROACIWII PERMIT APPLICATION DO- (01108) <br />