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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S�-5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3 Z <br /> UP-? VALID TO 3 V1 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 7�24C y QUAD xt1 <br /> /I •� Jv -7C ;cX:) TYPE z <br /> (Mailing Address) FORMS <br /> NOTES <br /> Cat <br /> (City,State,Zip Code) <br /> ���;� ;,mss•-/.�,s <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plan <br /> ■ <br /> f <br /> t <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the E«s% side of ���- ��, T/,�r ., approximately / feIeui <br /> Of -7 by performing the following work(descrip ion of work): <br /> � � L✓'// Z7 <br /> 2ZI .3 <br /> Work will commence on or about 31,71112 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 Date <br /> E:1PUB-SV.WKIMASTER.PMENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />