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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -Jz/1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# p�,3�?(r REF# <br /> Department of Public Works f APN CR# <br /> EXP.D <br /> VALID <br /> ATE Td LO <br /> ZD DRIVEWAYS: <br /> (Applicant Name) V STREET A3711 S1. &)7.&AE ,2`D, <br /> 2- 1 —DJ- #j,/fl AREA 2�iG QUAD <br /> TYPE fAoke ez"a tJC� <br /> (Mailing Address) FORMS <br /> If \J ur(1 , K 1 75/ O3 NOTES <br /> (City,State,Zip Code)(9 <br /> SS14g4 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of <br /> � r I✓i approximately feet/mile <br /> of <br /> _ <br /> by performing the following work(description of work): <br /> r <br /> o l.( poli �n <br /> i - � to >„ t `' ►' -� f <br /> A <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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title ate <br /> E:1PUB,W.%YKM5TERPS%ENCROACHkei PMMTAPPLICATICN.DOC(01M) <br />