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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> ID OFFICE USE ONLY <br /> To: San Joaquin County JOB# � ` - REF# <br /> Department of Public Works APN _ CR# <br /> -/R'ic EXP.DATE h hS <br /> r7�� VALID (o _ �, 1 - DRIVEWAYS: <br /> (Applicant Name) STREET Q.b <br /> ff AREA [ QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> C <br /> 9NOTES <br /> (City,Sta e,Zip Code) <br /> 7 5'' '�/ -7 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, onstruct and/or otherwise encroach on County High Right-of-Way on <br /> the-5o�,►-�- side of C_. r P approximately 35 Q fe mile t <br /> of r^ , by performing the following work description of work): <br /> m caa m CL o a <br /> PLit L <br /> & 1 a �� <br /> E <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 /> fire of Applicant-Title Date <br /> E:1PUB-SV.WKWASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />