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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> p� <br /> Departm t of Public Works APN CR#� <br /> EXP.DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET j <br /> 4040 Wg ✓► (�f AREA 017�r6'ge— Q UAD <br /> TYPE <br /> (Mailing Address) _ FORMS ,rs 1vy✓ ,�' <br /> $-�o c �� � CA �(,��Or/l NOTES <br /> (City,State,Zip Code) J `� <br /> (Area Code-Te e h e Number) <br /> 0 <br /> Sketch(Detailed plans may be submitted) <br /> See a4 Plar 1/1 <br /> Th( s 4pp <br /> (� CZc o� <br /> The u ersi n d hereby applieabr permiss'o to exc vate,construct and/or otherwise encr ch ori Co my High ray Right-of-Way on <br /> the side of E _ approximately fe ile <br /> of• ti,, ti.- , by performing the following work(description of work): <br /> Work will commence on or about 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 /> o v64 2 3 zvfZ <br /> Signature o Applicant-Title Date <br /> E:IPU&SVWKIMASTERPSIENCROACHMENTPERMRAPPLICATION.DOC (01108) <br />