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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �,,� — ( � OFFICE USE ONLY <br /> To: San Joaquin County JOB# l ee9 "' REF# <br /> Department of Public Works APN CR# <br /> I C _ EXP.DATE S"(?ter f- ,�'t S r1.C VALID TO 1 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> TYPE w-, <br /> (Mailing Address) FORMS S eN -2- <br /> low. rANOTES <br /> � � <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) oK Per Ve-s,9),1 Eng. 4".41 -taM <br /> The undersigned hereby applies or permission to cavate,construct and/or otherwise encroach on County HighOde <br /> Right-of-Way on <br /> the side of r�.ti„�._- ` approximatelyG aiiEof by performing the following work( ription of work): <br /> 1A 4c V6- <br /> M- zr/ti JC C� <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 /> ( l <br /> Signature 8f A icant-Title Date <br /> EAPUB-SV.WKWIASTER.PS%ENCROACHMENTPERMIT APPUCATION.DOC (01/08) <br />