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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: t <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name <br />(Mailing Address) <br />(City, State, Zip Code) <br />2e7l - dt6 >E) 1. <br />JArea Code - T epho a Number) <br />I <br />(Email Address) t <br />Sketch (Detailed plans may be submitted) <br />sem. A-T"rA6d94:V <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />No work in Asphalt all work will be located North of E. Alpine and <br />West of N. Belvedere in the on the Shoulder in the dirt. Attempt to locate COS sewer <br />laterial. <br />The u ersigned ereby appli s for <br />the side of <br />of _ L. <br />and/or otherwise encroach on County highway right-of-way on <br />approximately5 (9 feet/ 0 mile <br />, by performing the following work (description of work): <br />Work will commence on or after for approximately 71 kO 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 />41, <br />gnat re of nt - Title D to <br />