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4 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# OC � REF# <br /> Department of PublicWo s APN 2c�� -aS6— tz WHA ' y - _?-S6-cs <br /> EXP.DATE Z-!S=2G t Z <br /> 1 ) VALID �-2C-2plZ-TO 2-/,S z bz DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA s QUAD _SF — ' <br /> o2y6� P. 227a,e,;0Q5 TYPE UKe— C I z <br /> (Mailing Ad res ss) FORMS <br /> CA gsj�Q NOTES <br /> (City,State,Zip Code) <br /> oy 31/ 9 .70 <br /> (Area Code-T Iehone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned her y applies for permission to excavate,construct and/or otherwise encroach on County Hig Right-of-Way on <br /> the tor ► 19 So de of - o' approximately fe mile <br /> of C­roS ri by performing the following work(description of work): <br /> ir7 a./W *, <br /> ork will commence on or about — —ja. 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 /> 1r�1 ' �.3 '/ <br /> (!Pature of Applicant-Title Date <br /> E1RM-SV.WOVSTERPSIFNCROACHMErJT PERMIT APPLJCATION.DOC (01/08) <br />