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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �✓ OFFICE USE ONLY <br /> To: San Joaquin County JOB# l`DD0 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ff-bw VALID !b $ l3 DDRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA I QUAD SE <br /> 2 j,7G'y SJ` TYPE - IKP D CLOSLI <br /> (Mailing Address) FORMS <br /> NOTES <br /> AD ClO�U L�dyY1 <br /> �,�� (City,State,Zip Code) <br /> 00 <br /> o A/r1� nrU o Al <br /> (Area Code-Telephone Number) �� WSJ <br /> Sketch(Detailed plans may be submitted) <br /> p At <br /> G7-f'3 <br /> The undersigned hereby applies&(2P-6LJ-1T-6 <br /> permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of Zt) approximately <br /> �a AyFc} ?I�. ESGt,�v1�6 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 desc ed abgve in accordance ith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> E:IPUS-SV.WMMASTER.PSIENCROACHMENTPERMfTAPPLICATION.DOC(01108) <br />