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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# l�D4d�' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> X A1� VALID <br /> (Applica t Name) STREET T ls' DRIVEWAYS: <br /> iii �yF <br /> AREA Sl / QUAD &U5 <br /> TYPE �.t1�yJ.t/6y <br /> (Mailing Address) FORMS ,/, <br /> CS 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 excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the L.)e s� side of_ So ►� C?�e�l. w� approximate) <br /> of C l cv� Y Qn ee mile-_ sovt L, <br /> by performing the following work(description of work): <br /> Cew'Q r <br /> �eR1� � �o►,. <br /> Work will commence on or about <br /> 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 /> (� <br /> Signature of Applicant-Title S— <br /> Date <br /> E.IPU&SVWRIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (OM8( <br />