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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2l I�(I 3 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# ?j-4 REF# <br /> Department of Public Works APN A 11 CR# <br /> ; it 4 <br /> 4,GV� <br /> ���ZEXP.DATE VALID YO DRIVEWAYS: <br /> (Applicant Name) STREET GL <br /> AREA QUAD 645 <br /> t ve_ TYPE <br /> (Mailing Address) FORMS <br /> �- 9 31 Z� NOTES <br /> (City,State,Zip Code) <br /> sit, q!5q <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 1�i c.,p1 <br /> t4 lbw+ SEA - Se e A--r"r-A<*e D T)rawN c--& �r <br /> j r-cY,-t.rk l <br /> ` �c he est- CIWL s 724-o I(o d <br /> The and rsigned hereby applies fo permission to excavate,construct and/or otherwise encroach on County Highw ight-of-Way on <br /> the rr s' a of GtXx-Z X1*4 approximately Ile_i � <br /> of ,by performing the following war escription 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 accorda ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> "Ac'J" 1 �3 <br /> Signature of Applican -Title Date <br /> E:`PU&SV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATiON.DOC(01W) <br />