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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# /LI REF# <br /> Department of Public Works APN CR# <br /> f EXP.DATE <br /> C7zA'1''tE C;t>'as-;iztiC T&t '—) VALID / 0 / ii DRIVEWAYS: <br /> (Applicant Name) STREET iQ /y1EQ <br /> AREA QUAD <br /> j015 TYPE <br /> (Mailing Address) FORMS ,kJ <br /> NOTES <br /> (City,State,Zip Code) <br /> ? e <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for .ermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of Z-4,1 approximately AeOWe MWffifly <br /> .4 _Ain 41�1 , by performing the following work(description of work): <br /> j <br /> Work will commence on or about !l i/ for approximately. 2 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 /> ignature of Applicant-Title ate <br /> E:TUB-SV.WKWASTERPSIENCROACH6£NT PERMT APPLICATION.DOC (01108) <br />