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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73Gd72-l REF# <br /> Department of Public Works APN CR# <br /> 4 EXP.DATE / 2- <br /> VALID 43 <br /> J2_ 0 DRIVEWAYS: <br /> (Applicant Name) STREET _ <br /> t cAREA F .�s'oUAD j� <br /> le=\ l i lel TYPE <br /> cC (Mailing Address) FORMS < �,, -2_T <br /> J4C��O�I�Z � �� NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to exc vate,construct and/or otherwise encroach on Cqunty High Right- f-Way on <br /> the side of C approximately L feet/ He <br /> of `� Nr' a` `� 1" r Stitt y performing t e following work iption of work): <br /> Work will commence on or about L t�- 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 /> —\��- y 1 - r A- <br /> �� 1\ <br /> Signature of Applic - itle Dat <br /> E:IPIIB-SV.WKWWTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (07/08) <br />