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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I -� f I I OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> rr 11 EXP. DATE <br /> VALID 3 Tb DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ AREA QUAD <br /> TYPE r d� �r2��f Cn :ZdrGE <br /> (Mailing Address) FORMS wlr/ <br /> NOTES —� <br /> (City, State,Zip Code) <br /> 20 c� -- 9( 9 -- 8-�;- 7- <br /> (Area <br /> —(Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> l�•N-�� ` 1 . `���,�� Kam ��� <br /> o- o � �� <br /> The undersigned hereby applies for permissio to o excav4te,con truct and/or otherwise encroach on County Highway Right-of-Way on <br /> ,.tom sjde-6f Koapproximafely feetlmree <br /> -Q--v . by performing the following work(description of work): <br /> C) S 1 -S S , 0 ff S P,^t2 QcJ` <br /> // - 3� T <br /> Work will commence on or about f � <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 /> 1Z. <br /> Signature of Applicant-Title Date <br /> E:IPU8-SV.WNIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />