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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:11gli <br /> Date Q OFFICE USE ONLY <br /> To: San Joaquin County JOB# P(, I�,a REF# <br /> Department of Public Works APN CR# <br /> r EXP.DATE l0- 1-201 N <br /> '( im 10'I 0 If VALID 21- ( TO lk-1-2a� DRIVEWAYS: <br /> (Appli nt Name) STREET RNVe-V ' <br /> AREA QUAD CC <br /> �UI TYPE <br /> (Ma' mg Address) FORMS �S�W�.J, g-2 <br /> A NOTES <br /> ���J 6 City,Stat ,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans mq be submitted) <br /> CL <br /> The nder igned hereby appli br permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> th side of i V approximately 01 feet/mile A I--) — <br /> of Y,�, ., , by performing the following work(description of work): <br /> .1 ")LAO <br /> // s.4t4e • �' a <br /> I he, <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 /> Sign of Applicant-Title Date <br /> E:.UB-SV. R.PS,ENCROACRMENT PERMIT APPLICATION DOC (01 08) <br />