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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: p (n <br /> Date 2-0 1 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works REF# <br /> APN CR# <br /> ��'✓t�l� Y.YG� EXP.DATE l <br /> VALID $ J3 O <br /> (Applicant Name) STREET DRIVEWAYS:r � <br /> nn j� o * <br /> �Q� .;�`Tr�l'1 �-i r �f� � � �` �QQ TYPE � Yt C QUAD � <br /> (Mailing Address <br /> ) FORMS <br /> C- NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> PAP <br /> The undersigned hereby applies f r permission to excavate,construct /or otherwise <br /> the n�side of r� encroach on County Highway Ri ht-of--Way on <br /> of l . �ple <br /> Ry <br /> imately <br /> �� performing the following work(descnp ion of work): <br /> Y> '1 V <br /> Work will commence on or about �c t� U4 <br /> or approximately days. <br /> 47 <br /> S- �>�_�C�L I, the undersigned,certify that I am the owner of the respective property,or amqqualified to re <br /> work described abo '�-aeeefd a with the rules and regulations of San Joaquin Count andrsent the owner and agree to do the <br /> y subject to inspection and approval. <br /> Signature of Applicant-Title ( f� <br /> YAFORMS&TEMPLATESIENCROACHMENT PERMIT APPLICATION.doc(08/08) Date <br />